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1.
BMC Oral Health ; 19(1): 254, 2019 11 21.
Artigo em Inglês | MEDLINE | ID: mdl-31752793

RESUMO

BACKGROUND: Although several studies assessed the prevalence of alveolar bone loss, the association with several risk factors has not been fully investigated. The aim of this article is to measure the prevalence of periodontitis by calculating the mean alveolar bone loss/level of posterior teeth using bitewing radiographs among the patients enrolled in the clinics at Harvard School of Dental Medicine and address risk factors associated with the disease. METHODS: One thousand one hundred thirty-one patients were selected for radiographic analysis to calculate the mean alveolar bone loss/level by measuring the distance between the cementoenamel junction and the alveolar bone crest on the mesial and distal surfaces of posterior teeth. Linear regression with Multi-level mixed-effect model was used for statistical analysis adjusting for age, sex, race, median household income, and other variables. RESULTS: Mean alveolar bone level of the whole sample was 1.30 mm (±0.006). Overall periodontitis prevalence for the sample was 55.5% (±1.4%). Moderate periodontitis prevalence was 20.7% (±1.2%), while 2.8% (±0.5%) of the whole sample had severe periodontitis. Adjusted mean alveolar bone loss was higher in older age groups, males, Asian race group, ever smokers, and patients with low median household income. CONCLUSION: The effect of high household income on the amount of bone loss can be powerful to the degree that high household income can influence outcomes even for individuals who had higher risks of developing the disease. Public health professionals and clinicians need to collaborate with policy makers to achieve and sustain high quality of healthcare for everyone.


Assuntos
Perda do Osso Alveolar , Periodontite , Idoso , Perda do Osso Alveolar/etiologia , Processo Alveolar , Boston/epidemiologia , Assistência Odontológica , Feminino , Humanos , Masculino , Periodontite/complicações , Periodontite/epidemiologia , Prevalência
2.
Pediatrics ; 144(4)2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31501233

RESUMO

BACKGROUND AND OBJECTIVES: Food insecurity and pediatric obesity affect young children. We examine how food insecurity relates to obesity, underweight, stunting, health, and development among children <4 years of age. METHODS: Caregivers of young children participated in a cross-sectional survey at medical centers in 5 US cities. Inclusion criteria were age of <48 months. Exclusion criteria were severely ill or injured and private health insurance. The Household Food Security Survey Module defined 3 exposure groups: food secure, household food insecure and child food secure, and household food insecure and child food insecure. Dependent measures were obesity (weight-age >90th percentile), underweight (weight-age <5th percentile), stunting (height/length-age <5th percentile), and caregiver-reported child health and developmental risk. Multivariable logistic regression analyses, adjusted for demographic confounders, maternal BMI, and food assistance program participation examined relations between exposure groups and dependent variables, with age-stratification: 0 to 12, 13 to 24, 25 to 36, and 37 to 48 months of age. RESULTS: Within this multiethnic sample (N = 28 184 children, 50% non-Hispanic African American, 34% Hispanic, 14% non-Hispanic white), 27% were household food insecure. With 1 exception at 25 to 36 months, neither household nor child food insecurity were associated with obesity, underweight, or stunting, but both were associated with increased odds of fair or poor health and developmental risk at multiple ages. CONCLUSIONS: Among children <4 years of age, food insecurity is associated with fair or poor health and developmental risk, not with anthropometry. Findings support American Academy of Pediatrics recommendations for food insecurity screening and referrals to help families cope with economic hardships and associated stressors.


Assuntos
Desenvolvimento Infantil , Abastecimento de Alimentos/estatística & dados numéricos , Transtornos do Crescimento/epidemiologia , Nível de Saúde , Obesidade Pediátrica/epidemiologia , Magreza/epidemiologia , Afro-Americanos/estatística & dados numéricos , Fatores Etários , Arkansas/epidemiologia , Baltimore/epidemiologia , Boston/epidemiologia , Cuidadores/estatística & dados numéricos , Pré-Escolar , Estudos Transversais , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Minnesota/epidemiologia , Inquéritos Nutricionais , Philadelphia/epidemiologia , Pobreza , Análise de Regressão
3.
J Pediatr Orthop ; 39(9): e647-e651, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31503219

RESUMO

BACKGROUND: Incarcerated medial epicondyle fractures in association with elbow trauma are rare and an absolute indication for intervention. Because of the infrequent nature, outcomes following this injury are not well documented. We studied a large cohort of these injuries to determine factors associated with functional outcomes. It was hypothesized that a greater duration between initial presentation and time of surgery would lead to poorer outcomes. METHODS: A total of 32 patients aged 18 and under who underwent surgical treatment for an incarcerated medical epicondyle fracture at a level-1 pediatric trauma center from 2003 to 2015 were identified. All patients had a confirmed diagnosis of an incarcerated medial epicondyle at surgery. Medical records and radiographs were reviewed to determine the patient demographics, mechanism of injury, preoperative neurological symptoms, time of primary presentation, time of elbow reduction, and time to surgical intervention. Postoperative outcomes, including pain, range of motion, and ulnar nerve symptoms, were also collected. The Roberts outcome score was determined for each subject. RESULTS: A radiographically confirmed elbow dislocation was identified in 25 subjects. The mean age at injury was 13.2 years (range, 7.3 to 17.8 y). Initial presentation was at a referring institution in 30 patients (94%). First closed reduction attempt of the ulnohumeral joint occurred in the emergency room in 24 subjects (75%); of these 7 subjects (22%) had a first reduction attempted in the emergency room at our institution, 2 patients experienced first elbow reduction during surgical intervention. The median time from first presentation to surgery was 21.9 hours (interquartile range, 15 to 40). Fourteen subjects displayed preoperative ulnar nerve symptoms. Of these, 9 subsequently reported postoperative ulnar nerve symptoms. There was no effect of time to surgical intervention on the Roberts outcome scores at follow-up, nerve symptoms, symptomatic hardware, or need for second surgery to remove hardware. There were 16 subjects with excellent outcomes, 13 with good outcomes, 3 with fair outcomes, and 0 with poor outcomes (based on the Roberts criteria). CONCLUSIONS: Incarcerated medial epicondyle fractures are commonly associated with ulnar nerve symptoms; however, they are not associated with a significant rate of other complications. There was no increased risk of complications in subjects who had a longer duration between initial presentation and surgery. This suggests that, while the presence of an incarcerated medial epicondyle fracture is certainly an indication for timely operative intervention; the injury in isolation does not need to be considered emergent. Other factors including neurovascular status and ability to achieve joint reduction may still necessitate emergency operative care. LEVEL OF EVIDENCE: Level IV-therapeutic study, case series.


Assuntos
Articulação do Cotovelo/lesões , Fraturas do Úmero/reabilitação , Complicações Pós-Operatórias/epidemiologia , Adolescente , Boston/epidemiologia , Criança , Cotovelo/lesões , Articulação do Cotovelo/diagnóstico por imagem , Articulação do Cotovelo/patologia , Articulação do Cotovelo/cirurgia , Feminino , Fixação Interna de Fraturas , Humanos , Fraturas do Úmero/epidemiologia , Fraturas do Úmero/patologia , Fraturas do Úmero/cirurgia , Luxações Articulares/cirurgia , Masculino , Morbidade , Radiografia , Amplitude de Movimento Articular , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Nervo Ulnar , Neuropatias Ulnares/epidemiologia
4.
Bone Joint J ; 101-B(9): 1081-1086, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474135

RESUMO

AIMS: The practice of alternating operating theatres has long been used to reduce surgeon idle time between cases. However, concerns have been raised as to the safety of this practice. We assessed the payments and outcomes of total knee arthroplasty (TKA) performed during overlapping and nonoverlapping days, also comparing the total number of the surgeon's cases and the total time spent in the operating theatre per day. MATERIALS AND METHODS: A retrospective analysis was performed on the Centers for Medicare & Medicaid Services (CMS) Limited Data Set (LDS) on all primary elective TKAs performed at the New England Baptist Hospital between January 2013 and June 2016. Using theatre records, episodes were categorized into days where a surgeon performed overlapping and nonoverlapping lists. Clinical outcomes, economic outcomes, and demographic factors were calculated. A regression model controlling for the patient-specific factors was used to compare groups. Total orthopaedic cases and aggregate time spent operating (time between skin incision and closure) were also compared. RESULTS: A total of 3633 TKAs were performed (1782 on nonoverlapping days; 1851 on overlapping days). There were no differences between the two groups for length of inpatient stay, payments, mortality, emergency room visits, or readmission during the 90-day postoperative period. The overlapping group had 0.74 fewer skilled nursing days (95% confidence interval (CI) -0.26 to -1.22; p < 0.01), and 0.66 more home health visits (95% CI 0.14 to 1.18; p = 0.01) than the nonoverlapping group. On overlapping days, surgeons performed more cases per day (5.01 vs 3.76; p < 0.001) and spent more time operating (484.55 minutes vs 357.17 minutes; p < 0.001) than on nonoverlapping days. CONCLUSION: The study shows that the practice of alternating operating theatres for TKA has no adverse effect on the clinical outcome or economic utilization variables measured. Furthermore, there is opportunity to increase productivity with alternating theatres as surgeons with overlapping cases perform more cases and spend more time operating per day. Cite this article: Bone Joint J 2019;101-B:1081-1086.


Assuntos
Artroplastia do Joelho/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Salas Cirúrgicas/estatística & dados numéricos , Duração da Cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho/economia , Boston/epidemiologia , Bases de Dados Factuais/estatística & dados numéricos , Eficiência Organizacional/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/economia , Feminino , Humanos , Tempo de Internação , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Salas Cirúrgicas/organização & administração , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos/epidemiologia
5.
Am J Obstet Gynecol ; 221(3): 271.e1-271.e10, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31229427

RESUMO

BACKGROUND: The obstetric comorbidity index summarizes the burden of maternal comorbidities into a single number and holds promise as a maternal risk-assessment tool. OBJECTIVE: The aim of this study was to assess the clinical performance of this comorbidity-based screening tool to accurately identify women on labor and delivery who are at risk of severe maternal morbidity on labor and delivery in real time. STUDY DESIGN: All patients with pregnancies ≥23 weeks gestation presenting to labor and delivery at a single tertiary-care center from February through July 2018 were included in the study. The patient's primary labor and delivery nurse assessed patient comorbidities and calculated the patient's obstetric comorbidity index. The score was recalculated at each 12-hour shift change. A multidisciplinary panel of clinicians determined whether patients experienced severe maternal morbidity based on the American College of Obstetrics and Gynecology and Society for Maternal-Fetal Medicine consensus definition, blinded to the patient's obstetric comorbidity index score. We analyzed the association between the obstetric comorbidity index score and the occurrence of severe maternal morbidity. RESULTS: The study included 2828 women, of whom 1.73% experience severe maternal morbidity (n=49). The obstetric comorbidity index ranged from 0-15 for women in the study cohort, with a median obstetric comorbidity index of 1 (interquartile range, 0-3). The median obstetric comorbidity index score for women who experienced the severe maternal morbidity was 5 (interquartile range, 3-7) compared with a median of 1 (interquartile range, 0-3) for those without severe maternal morbidity (P<.01). The frequency of severe maternal morbidity increased from 0.41% for those with a score of 0 to 18.75% for those with a score ≥9. For every 1-point increase in the score, patients experienced a 1.55 increase in odds of severe maternal morbidity (95% confidence interval, 1.42-1.70). The c-statistic for the obstetric comorbidity index score was 0.83 (95% confidence interval, 0.76-0.89), which indicated strong discrimination. CONCLUSION: The obstetric comorbidity index can prospectively identify women at risk of severe maternal morbidity in a clinical setting. A particular strength of the obstetric comorbidity index is its ability to integrate multiple compounding comorbidities and highlight the cumulative risk that is associated with the patients' conditions. Routine clinical use of the obstetric comorbidity index has the potential to identify at-risk women whose condition warrants increased surveillance and targeted care to prevent adverse maternal outcomes.


Assuntos
Complicações na Gravidez/diagnóstico , Adulto , Boston/epidemiologia , Comorbidade , Parto Obstétrico , Feminino , Humanos , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/epidemiologia , Complicações do Trabalho de Parto/etiologia , Complicações do Trabalho de Parto/prevenção & controle , Gravidez , Complicações na Gravidez/epidemiologia , Estudos Prospectivos , Medição de Risco , Índice de Gravidade de Doença
6.
Pediatrics ; 143(5)2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30952779

RESUMO

BACKGROUND: Severe neonatal hyperbilirubinemia (>20 mg/dL) affects ∼1 million infants annually. Improved jaundice screening in low-income countries is needed to prevent bilirubin encephalopathy and mortality. METHODS: The Bili-ruler is an icterometer for the assessment of neonatal jaundice that was designed by using advanced digital color processing. A total of 790 newborns were enrolled in a validation study at Brigham and Women's Hospital (Boston) and Sylhet Osmani Medical College Hospital (Sylhet, Bangladesh). Independent Bili-ruler measurements were made and compared with reference standard transcutaneous bilirubin (TcB) and total serum bilirubin (TSB) concentrations. RESULTS: Bili-ruler scores on the nose were correlated with TcB and TSB levels (r = 0.76 and 0.78, respectively). The Bili-ruler distinguished different clinical thresholds of hyperbilirubinemia, defined by TcB, with high sensitivity and specificity (score ≥3.5: 90.1% [95% confidence interval (CI): 84.8%-95.4%] and 85.9% [95% CI: 83.2%-88.6%], respectively, for TcB ≥13 mg/dL). The Bili-ruler also performed reasonably well compared to TSB (score ≥3.5: sensitivity 84.5% [95% CI: 79.1%-90.3%] and specificity 83.2% [95% CI: 76.1%-90.3%] for TSB ≥11 mg/dL). Areas under the receiver operating characteristic curve for identifying TcB ≥11, ≥13, and ≥15 were 0.92, 0.93, and 0.94, respectively, and 0.90, 0.87, and 0.86 for identifying TSB ≥11, ≥13, and ≥15. Interrater reliability was high; 97% of scores by independent readers fell within 1 score of one another (N = 88). CONCLUSIONS: The Bili-ruler is a low-cost, noninvasive tool with high diagnostic accuracy for neonatal jaundice screening. This device may be used to improve referrals from community or peripheral health centers to higher-level facilities with capacity for bilirubin testing and/or phototherapy.


Assuntos
Recursos em Saúde/economia , Icterícia Neonatal/diagnóstico , Icterícia Neonatal/economia , Triagem Neonatal/economia , Triagem Neonatal/instrumentação , Adulto , Bangladesh/epidemiologia , Boston/epidemiologia , Cor , Feminino , Recursos em Saúde/tendências , Humanos , Hiperbilirrubinemia Neonatal/diagnóstico , Hiperbilirrubinemia Neonatal/economia , Hiperbilirrubinemia Neonatal/epidemiologia , Recém-Nascido , Icterícia/diagnóstico , Icterícia/economia , Icterícia/epidemiologia , Icterícia Neonatal/epidemiologia , Masculino , Triagem Neonatal/tendências , Adulto Jovem
7.
J Acquir Immune Defic Syndr ; 81(2): 184-192, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-30839380

RESUMO

BACKGROUND: Worldwide, young transgender women (YTW) contend with exceptionally high risks of HIV infection. Cross-sectional studies have suggested that co-occurring epidemics or "syndemics" of psychosocial problems may accelerate HIV acquisition and transmission through elevated sexual risk behavior among transgender women. We aimed to examine how a syndemic of 7 psychosocial problems potentiates HIV sexual risk behavior among a multicity, longitudinal cohort of sexually active YTW in the United States. METHODS: Between 2012 and 2015, 233 YTW from Boston, MA, and Chicago, IL, completed behavioral surveys at baseline, 4, 8, and 12 months. We used generalized estimating equations to examine the prospective relationship of overlapping psychosocial problems and HIV sexual risk behavior (ie, condomless anal or vaginal sex) among YTW. RESULTS: The prevalence of 7 psychosocial syndemic problems was substantial at baseline and remained high at each time point: 6.4% reported polydrug use in the past 4 months (excluding stimulants); 7.7% reported heavy alcohol use in the past 4 months; 10% reported a history of childhood sexual abuse; 15.9% reported stimulant use in the past 4 months; 41.7% reported experiencing lifetime intimate partner violence; 42.1% reported clinically significant depressive symptoms; and 68.6% reported lifetime transgender-specific victimization. We identified a statistically significant positive "dose-response" relationship between the number of psychosocial syndemic problems and condomless anal or vaginal sex over time. CONCLUSIONS: The accumulation of "syndemic" psychosocial problems predicted HIV sexual risk behavior in a prospective cohort of YTW. Given the high prevalence of psychosocial problems and HIV sexual risk behavior, as well as having the highest HIV incidence among any risk group, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with gender-affirming and supportive mental health, violence recovery, and addiction treatment services for this population.


Assuntos
Infecções por HIV/epidemiologia , Infecções por HIV/psicologia , Assunção de Riscos , Comportamento Sexual/psicologia , Sindemia , Pessoas Transgênero/psicologia , Adolescente , Adulto , Boston/epidemiologia , Chicago/epidemiologia , Criança , Abuso Sexual na Infância/estatística & dados numéricos , Vítimas de Crime/estatística & dados numéricos , Estudos Transversais , Depressão/epidemiologia , Feminino , Humanos , Incidência , Violência por Parceiro Íntimo/estatística & dados numéricos , Estudos Longitudinais , Masculino , Prevalência , Estudos Prospectivos , Fatores de Risco , Comportamento Sexual/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Inquéritos e Questionários , Pessoas Transgênero/estatística & dados numéricos , Estados Unidos , Sexo sem Proteção/estatística & dados numéricos , Adulto Jovem
8.
J Pediatr Orthop ; 39(6): e417-e421, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30817417

RESUMO

BACKGROUND: There has been little investigation into the epidemiology of Cozen's phenomenon, genu valgum as a complication of proximal tibial metaphysis fractures. In this study, we present a large case series of proximal tibia fractures in children to describe the prevalence, epidemiology, and characteristics associated with Cozen's phenomenon following proximal tibial fracture in children. METHODS: We searched the orthopedic database at our institution for all patients aged 1 to 8 years old with proximal tibia fractures presenting for initial fracture management between January 1, 2014 and December 31, 2017. Demographic data, mechanism of injury, fracture characteristics, and the presence of a concurrent fibula fracture were determined from the medical records. Initial and follow-up valgus angulation was measured as the angle between a line perpendicular to the proximal tibial physis and a line drawn along the axis of the tibia. Differences in the rate of valgus angulation by mechanism of injury and fracture type were compared. RESULTS: In total, 181 fractures in 181 patients were included in our study (98 male, 83 female). The average age at injury was 4.55 years (range, 1.02 to 7.95 y); 140 patients (77.3%, 140/181) had initial valgus angulation of <4 degrees; 20 of these patients (14.3%, 20/140) developed angulation of at least 4 degrees at some point during follow-up at an average of 0.8 months (range, 0.2 to 1.9 mo); 4 patients (20.0%, 4/20) with <4 degrees of initial angulation had persistent valgus angulation of 5 degrees at latest follow-up. Two of these patients were not scheduled to return because the provider did not determine the valgus angulation to be clinically meaningful. The 2 other patients were asymptomatic and continued to receive nonoperative management. No patients in our series required surgical correction of valgus deformity. CONCLUSIONS: Cozen's phenomenon is an uncommon complication of proximal tibial metaphysis fractures. Eliminating unnecessary radiographs and clinical visits for our pediatric trauma patients will improve the quality and value of care delivery. LEVEL OF EVIDENCE: Level IV.


Assuntos
Geno Valgo/epidemiologia , Fraturas da Tíbia/cirurgia , Boston/epidemiologia , Criança , Pré-Escolar , Feminino , Geno Valgo/complicações , Geno Valgo/diagnóstico por imagem , Lâmina de Crescimento/diagnóstico por imagem , Humanos , Lactente , Masculino , Prevalência , Radiografia , Fraturas da Tíbia/complicações
9.
Artigo em Inglês | MEDLINE | ID: mdl-30736407

RESUMO

While studies of bicyclist's perceptions of crime and crash safety exist, it is also important to ask lower-income predominantly-minority residents what bicycle-route surface or context they perceive as safest from crime and crashes. With their insights, their chosen bike environments could be in engineering guidelines and built in their neighborhoods to improve residents' health and lessen their risk of exposure to crime or crashing. This study involved two populations in Boston: (a) community-sense participants (eight groups-church/YMCA n = 116); and (b) street-sense participants (five groups-halfway house/homeless shelter/gang members n = 96). Participants ranked and described what they saw in 32 photographs of six types of bicycle environments. Quantitative data (Likert Scale 0⁻6 with 0 being low risk of crime/crash) involved regression analysis to test differences. Qualitative comments were categorized into 55 themes for surface or context and if high or low in association with crime or crashes. For crime, two-way cycle tracks had a significantly lower score (safest) than all others (2.35; p < 0.01) and share-use paths had a significantly higher score (least safe) (3.39; p < 0.01). For crashes, participants rated shared-use paths as safest (1.17) followed by two-way cycle tracks (1.68), one-way cycle tracks (2.95), bike lanes (4.06), sharrows (4.17), and roads (4.58), with a significant difference for any two groups (p < 0.01) except between bike lane and sharrow (p = 0.9). Street-sense participants ranked all, except shared-use paths, higher for crime and crash. For surface, wide two-way cycle tracks with freshly painted lines, stencils, and arrows were low risk for crime and a cycle track's median, red color, stencils, and arrows low risk for crash. For context, clean signs, balconies, cafes, street lights, no cuts between buildings, and flowers were low risk for crime and witnesses, little traffic, and bike signals low risk for crash. As bicycle design guidelines and general Crime Perception Through Environmental Design (CPTED) principles do not include these details, perhaps new guidelines could be written.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Ciclismo/psicologia , Crime/estatística & dados numéricos , Planejamento Ambiental , Pobreza/estatística & dados numéricos , Acidentes de Trânsito/psicologia , Adolescente , Adulto , Idoso , Boston/epidemiologia , Crime/psicologia , Feminino , Pessoas em Situação de Rua , Humanos , Masculino , Pessoa de Meia-Idade , Grupos Minoritários , Pobreza/psicologia , Segurança , Fatores Socioeconômicos , Adulto Jovem
10.
AIDS Behav ; 23(4): 835-846, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30737609

RESUMO

Latino immigrants with substance use and mental health problems are at risk for undiagnosed HIV and sexually transmitted infections (STIs). Participants in a randomized control trial were recruited in Boston, USA and Madrid and Barcelona, Spain. Eligibility criteria were Latino self-identification, age 18-70, elevated substance use and mental health symptoms, and not currently in substance or mental health care. A multinomial logistic regression examined predictors of HIV/STI testing decline and lost to follow-up (LTFU) prior to testing compared with acceptance. Of 341 participants, 74% accepted testing, 4% declined, and 22% were LTFU. The odds of LTFU were higher in those with high concern for HIV and those whose main partner had done HIV testing. Age ≥ 35 years, females, higher education, and higher report of discrimination lowered the odds of LTFU. Delivery of HIV/STI testing through community agencies and outreach could overcome barriers to HIV/STI diagnosis in this population of Latinos.Clinical Trial Number: NCT02038855.


Assuntos
Emigrantes e Imigrantes/estatística & dados numéricos , Infecções por HIV/diagnóstico , Hispano-Americanos/estatística & dados numéricos , Programas de Rastreamento/estatística & dados numéricos , Transtornos Mentais/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Doenças Sexualmente Transmissíveis/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/psicologia , Adolescente , Adulto , Idoso , Boston/epidemiologia , Feminino , Infecções por HIV/etnologia , Infecções por HIV/psicologia , Humanos , Perda de Seguimento , Masculino , Transtornos Mentais/etnologia , Saúde Mental , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Testes Sorológicos , Parceiros Sexuais , Doenças Sexualmente Transmissíveis/etnologia , Doenças Sexualmente Transmissíveis/psicologia , Espanha/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/etnologia
11.
BMJ Open ; 9(1): e022896, 2019 01 25.
Artigo em Inglês | MEDLINE | ID: mdl-30782690

RESUMO

OBJECTIVE: The role of platelet-to-lymphocyte ratio (PLR) as an indicator of inflammation has been the focus of research recently. We aimed to investigate the prognostic value of PLR for sepsis. DESIGN: A retrospective cohort study. SETTING AND PARTICIPANTS: Data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care III database. Data on 5537 sepsis patients were analysed. METHODS: Logistic regression was used to explore the association between PLR and hospital mortality. Subgroup analyses were performed based on vasopressor use, acute kidney injury (AKI) and a Sequential Organ Failure Assessment (SOFA) score >10. RESULTS: In the logistic model with linear spline function, a PLR >200 was significantly (OR 1.0002; 95% CI 1.0001 to 1.0004) associated with mortality; the association was non-significant for PLRs ≤200 (OR 0.997; 95% CI 1.19 to 1.67). In the logistic model using the PLR as a design variable, only high PLRs were significantly associated with mortality (OR 1.29; 95% CI 1.09 to 1.53); the association with low PLRs was non-significant (OR 1.15; 95% CI 0.96 to 1.38). In the subgroups with vasopressor use, AKI and a SOFA score >10, the association between high PLR and mortality was non-significant; this remained significant in the subgroups without vasopressor use (OR 1.39; 95% CI 1.08 to 1.77) and AKI (OR 1.54; 95% CI 1.20 to 1.99) and with a SOFA score ≤10 (OR 1.51; 95% CI 1.17 to 1.94). CONCLUSIONS: High PLRs at admission were associated with an increased risk of mortality. In patients with vasopressor use, AKI or a SOFA score >10, this association was non-significant.


Assuntos
Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/mortalidade , Sepse/diagnóstico , Sepse/mortalidade , Lesão Renal Aguda/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Boston/epidemiologia , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Modelos Logísticos , Contagem de Linfócitos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Contagem de Plaquetas , Prognóstico , Curva ROC , Estudos Retrospectivos , Sepse/sangue
12.
JAMA Cardiol ; 4(3): 223-229, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30810703

RESUMO

Importance: To our knowledge, REPRISE III is the first large randomized comparison of 2 different transcatheter aortic valve replacement platforms: the mechanically expanded Lotus valve (Boston Scientific) and self-expanding CoreValve (Medtronic). Objective: To evaluate outcomes of Lotus vs CoreValve after 2 years. Design, Setting, and Participants: A total of 912 patients with high/extreme risk and severe, symptomatic aortic stenosis enrolled between September 22, 2014, and December 24, 2015, were randomized 2:1 to receive Lotus (607 [66.6%]) or CoreValve (305 [33.4%] at 55 centers in North America, Europe, and Australia. The first 2-year visit occurred on October 17, 2016, and the last was conducted on April 12, 2018. Clinical and echocardiographic assessments are complete through 2 years and will continue annually through 5 years. Main Outcomes and Measures: All-cause mortality and all-cause mortality or disabling stroke at 2 years. Other clinical factors included overall stroke, disabling stroke, repeated procedures, rehospitalization, valve thrombosis, and pacemaker implantation. Echocardiographic analyses included effective orifice area, mean gradient, and paravalvular leaks (PVLs). Results: Of 912 participants, the mean (SD) age was 82.8 (7.3) years, 465 (51%) were women, and the mean (SD) Society of Thoracic Surgeons predicted risk of mortality was 6.8% (4.0%). At 2 years, all-cause death was 21.3% with Lotus vs 22.5% with CoreValve (hazard ratio [HR], 0.94; 95% CI, 0.69-1.26; P = .67) and all-cause mortality or disabling stroke was 22.8% with Lotus and 27.0% with CoreValve (HR, 0.81; 95% CI, 0.61-1.07; P = .14). Overall stroke was 8.4% vs 11.4% (HR, 0.75; 95% CI, 0.48-1.17; P = .21); disabling stroke was more frequent with CoreValve vs Lotus (4.7% Lotus vs 8.6% CoreValve; HR, 0.53; 95% CI, 0.31-0.93; P = .02). More Lotus patients received a new permanent pacemaker (41.7% vs 26.1%; HR, 1.87; 95% CI, 1.41-2.49; P < .01) or had a valve thrombosis (3.0% vs 0.0%; P < .01) compared with CoreValve. More patients who received CoreValve experienced a repeated procedure (0.6% Lotus vs 2.9% CoreValve; HR, 0.19; 95% CI, 0.05-0.70; P < .01), valve migration (0.0% vs 0.7%; P = .05), or embolization (0.0% vs 2.0%; P < .01) than Lotus. Valve areas remained significantly larger and the mean gradient was lower with CoreValve than Lotus (valve area, mean [SD]: Lotus, 1.53 [0.49] cm2 vs CoreValve, 1.76 [0.51] cm2; P < .01; valve gradient, mean [SD]: Lotus, 13.0 [6.7] mm Hg vs 8.1 [3.7] mm Hg; P < .01). Moderate or greater PVL was more frequent with CoreValve (0.3% Lotus vs 3.8% CoreValve; P < .01) at 2 years. Larger improvements in New York Heart Association (NYHA) functional class were observed with Lotus compared with CoreValve (improved by ≥1 NYHA class: Lotus, 338 of 402 [84.1%] vs CoreValve, 143 of 189 [75.7%]; P = .01; improved by ≥2 NYHA classes: 122 of 402 [37.3%] vs 65 of 305 [21.3%]). Conclusions and Relevance: After 2 years, all-cause mortality rates, mortality or disabling stroke were similar between Lotus and CoreValve. Disabling stroke, functional class, valve migration, and PVL favored the Lotus arm whereas valve hemodynamics, thrombosis, and new pacemaker implantation favored the CoreValve arm. Trial Registration: clinicaltrials.gov Identifier: NCT02202434.


Assuntos
Estenose da Valva Aórtica/cirurgia , Próteses Valvulares Cardíacas/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/patologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/patologia , Austrália/epidemiologia , Boston/epidemiologia , Ecocardiografia/métodos , Europa (Continente)/epidemiologia , Feminino , Próteses Valvulares Cardíacas/estatística & dados numéricos , Humanos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Desenho de Prótese/tendências , Índice de Gravidade de Doença , Acidente Vascular Cerebral/etiologia , Trombose/etiologia , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento
14.
Dig Dis Sci ; 64(8): 2359-2367, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30761472

RESUMO

OBJECTIVES: There are few studies addressing the impact of cephalosporin and quinolone resistance on hospital length of stay and mortality in spontaneous bacterial peritonitis (SBP). We aim to describe the shifting epidemiology of SBP at our institution and its impact on clinical outcomes. METHODS: We performed a single-center retrospective cohort study of all cases of SBP from 2005 to 2015 at a transplant center. Cases were identified using hospital billing data. Patient data were confirmed using the electronic medical record. Univariate and multivariate logistic regression and Cox proportional hazards models were used to identify factors that were associated with prolonged hospital length of stay and reduced survival. Culture-positive cases (N = 56) were compared to culture-negative cases (N = 104). Subpopulation analysis of the culture-positive cases compared ceftriaxone-resistant (N = 25) to ceftriaxone-susceptible (N = 31) cases. RESULTS: We identified 160 cases of SBP (56 culture positive and 104 culture negative; 21 nosocomial, 79 hospital associated, and 60 community acquired). Forty-five percent (N = 25 total, 13 hospital associated and 6 nosocomial) of bacterial isolates were resistant to ceftriaxone, with 37.5% (N = 21) being gram positive, including 8 methicillin-resistant staphylococcus and 6 vancomycin-resistant enterococcus. Multivariate analysis identified hospital-associated SBP, age, alcoholic cirrhosis, and MELD-Na score as variables associated with worse survival (P < 0.05), with a trend toward worse survival in culture-positive cases (P = 0.123). Only MELD-Na was associated with prolonged length of stay. CONCLUSIONS: The burden of resistant pathogens causing SBP is significant, notably in hospital-associated SBP. Culture-positive SBP may represent a higher risk group compared to culture-negative SBP.


Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Ceftriaxona/uso terapêutico , Farmacorresistência Bacteriana , Cirrose Hepática/epidemiologia , Peritonite/tratamento farmacológico , Quinolonas/uso terapêutico , Adulto , Idoso , Infecções Bacterianas/diagnóstico , Infecções Bacterianas/microbiologia , Infecções Bacterianas/mortalidade , Boston/epidemiologia , Feminino , Humanos , Tempo de Internação , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Peritonite/diagnóstico , Peritonite/microbiologia , Peritonite/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
PLoS One ; 14(2): e0212439, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30763372

RESUMO

BACKGROUND: Critically ill patients may die despite invasive intervention. In this study, we examine trends in the application of two such treatments over a decade, namely, endotracheal ventilation and vasopressors and inotropes administration, as well as the impact of these trends on survival durations in patients who die within a month of ICU admission. METHODS: We considered observational data available from the MIMIC-III open-access ICU database and collected within a study period between year 2002 up to 2011. If a patient had multiple admissions to the ICU during the 30 days before death, only the first stay was analyzed, leading to a final set of 6,436 unique ICU admissions during the study period. We tested two hypotheses: (i) administration of invasive intervention during the ICU stay immediately preceding end-of-life would decrease over the study time period and (ii) time-to-death from ICU admission would also decrease, due to the decrease in invasive intervention administration. To investigate the latter hypothesis, we performed a subgroups analysis by considering patients with lowest and highest severity. To do so, we stratified the patients based on their SAPS I scores, and we considered patients within the first and the third tertiles of the score. We then assessed differences in trends within these groups between years 2002-05 vs. 2008-11. RESULTS: Comparing the period 2002-2005 vs. 2008-2011, we found a reduction in endotracheal ventilation among patients who died within 30 days of ICU admission (120.8 vs. 68.5 hours for the lowest severity patients, p<0.001; 47.7 vs. 46.0 hours for the highest severity patients, p = 0.004). This is explained in part by an increase in the use of non-invasive ventilation. Comparing the period 2002-2005 vs. 2008-2011, we found a reduction in the use of vasopressors and inotropes among patients with the lowest severity who died within 30 days of ICU admission (41.8 vs. 36.2 hours, p<0.001) but not among those with the highest severity. Despite a reduction in the use of invasive interventions, we did not find a reduction in the time to death between 2002-2005 vs. 2008-2011 (7.8 days vs. 8.2 days for the lowest severity patients, p = 0.32; 2.1 days vs. 2.0 days for the highest severity patients, p = 0.74). CONCLUSION: We found that the reduction in the use of invasive treatments over time in patients with very poor prognosis did not shorten the time-to-death. These findings may be useful for goals of care discussions.


Assuntos
Cuidados Críticos , Estado Terminal/mortalidade , Estado Terminal/terapia , Unidades de Terapia Intensiva , Suspensão de Tratamento , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Boston/epidemiologia , Morte , Feminino , Humanos , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Prognóstico , Assistência Terminal/tendências , Fatores de Tempo , Vasoconstritores/uso terapêutico , Suspensão de Tratamento/tendências , Adulto Jovem
16.
J Nutr ; 149(1): 78-87, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30624677

RESUMO

Background: People with HIV (PWH) are at risk for developing metabolic comorbidities driven, in part, by immune activation/inflammation. Little is known about diet quality, a potential modifiable factor in PWH. Objectives: This study aimed to explore diet quality in terms of conformance with US dietary guidelines by calculating Healthy Eating Index-2010 (HEI) scores among adults with and without HIV in Boston, MA, and determine associations with HEI and markers of immune activation/inflammation. Methods: One-hundred and three HIV-infected [50 women, 53 men; mean ± SD age: 47 ± 7 y; body mass index (BMI, in kg/m2): 26 ± 5] and 38 uninfected adults (17 women, 21 men; age: 46 ± 7 y; BMI: 28 ± 4) were included in this cross-sectional analysis. Participants who completed a 4-d food record from which HEI could be calculated were included. HEI was compared between participants with and without HIV, within HIV-infected participants stratified by sex, and by HIV serostatus and sex. In the HIV group, predictors of HEI were determined in multivariable modeling. Univariate associations with diet quality and inflammation/immune markers were assessed. Results: The HEI score was 51.3 in the HIV-infected participants and 57.3 in the HIV-uninfected participants (P = 0.052). In the comparison by HIV serostatus and sex, HIV-infected women had significantly lower HEI (49.2) compared with HIV-infected men (55.7) (P = 0.005) and HIV-uninfected men (61.8) (P = 0.002). Adjusting for potential confounding factors, sex remained an independent predictor of HEI in HIV (P = 0.02). In the HIV group, higher log HEI was associated with lower concentration of the immune activation marker sCD14 (P = 0.009). Conclusions: Diet quality tended to be lower in HIV-infected individuals compared with HIV-uninfected individuals and was lower among HIV-infected women compared with HIV-infected men, and HIV-uninfected men. There may also be an association with diet quality and sCD14 in PWH. Future prospective studies are needed to confirm these findings and determine whether improving diet quality is a useful strategy to reduce metabolic abnormalities in this population. This study was registered at clinicaltrials.gov as NCT00455793.


Assuntos
Dieta/normas , Infecções por HIV , Adulto , Boston/epidemiologia , Estudos Transversais , Inquéritos sobre Dietas , Feminino , Infecções por HIV/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Política Nutricional , Estudos Prospectivos , Fatores Sexuais
17.
BMC Psychiatry ; 19(1): 16, 2019 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-30626372

RESUMO

BACKGROUND: Trans-masculine (TM) individuals, who are assigned female sex at birth and identify along the masculine gender spectrum, face mental health disparities relative to cisgender people. Limited research has sought to explore the multi-level risk and protective factors associated with mental health morbidity for TM populations. METHODS: Between August 2015-September 2016, 150 TM adults were enrolled in a one-time biobehavioral health study. A survey assessed socio-demographics, past 12-month everyday discrimination, lifetime intimate partner violence (IPV), resilience (using the Brief Resilience Scale), and other factors. Bivariate and multivariable logistic regression analyses examined associations between participant characteristics and four mental health statuses: post-traumatic stress disorder (PTSD), depression, anxiety, and non-suicidal self-injury (NSSI). RESULTS: In this sample (76.7% had a binary gender identity, i.e., man or transgender man; 74.7% were white, 70.0% were under age 30 years), 42.2% had PTSD based on past 30-day symptoms; 25.7% had depression based on past 7-day symptoms; 31.1% had anxiety based on past 7-day symptoms; and 31.3% had engaged in NSSI within the past 12-months. Results from multivariable models: 1) PTSD: unemployment, lifetime IPV and past 12-month discrimination were each associated with increased odds of PTSD, while having a partner was associated with the reduced odds of PTSD. 2) Depression: lower educational attainment and past 12-month discrimination were each associated with the increased odds of depression, while greater resilience was associated with the reduced odds of depression. 3) Anxiety: low annual household income and past 12-month discrimination were each associated with the increased odds of anxiety, while resilience was associated with the reduced odds of anxiety. 4) NSSI: past 12-month discrimination was associated with the increased odds of past 12-month NSSI, while higher age and greater resilience was associated with the reduced odds of NSSI (all p-values < 0.05). CONCLUSIONS: Unemployment, low income, limited education, everyday discrimination, and violence were risk factors for poor mental health, while being in a relationship, higher age, and personal resilience were protective against mental health morbidity. Findings highlight the need for interventions to address the individual, interpersonal, and societal factors that may be driving poor mental health in this population.


Assuntos
Identidade de Gênero , Fatores de Proteção , Pessoas Transgênero/psicologia , Pessoas Transgênero/estatística & dados numéricos , Adulto , Ansiedade/epidemiologia , Boston/epidemiologia , Depressão/epidemiologia , Feminino , Humanos , Violência por Parceiro Íntimo/psicologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Comportamento Autodestrutivo/epidemiologia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Inquéritos e Questionários , Adulto Jovem
18.
Radiology ; 290(3): 722-729, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30599096

RESUMO

Purpose To investigate rates and causes of 30-day readmission for patients who undergo percutaneous transhepatic biliary drainage (PTBD) procedures. Materials and Methods In this retrospective study, PTBD procedures performed at a tertiary care institution (June 2008 to May 2013) were reviewed. For each patient, the first 30-day readmission was used to determine cause of readmission. Two interventional radiologists independently categorized causes for readmission as planned or unplanned, and unplanned causes as related to or unrelated to interventional radiology. Interventional radiology-related readmissions were categorized as potentially preventable or unpreventable. Factors associated with higher odds for 30-day readmission were identified with univariable and multivariable analysis. Results There were 266 procedures in 266 patients (mean age, 67 years; interquartile range, 57-76 years; 53.4% men). The cause of obstruction was malignant in 50.0% of patients (133 of 266). There were 122 of 266 patients (45.9%) readmitted within 30 days. Of these readmissions, 44 of 122 (36.1%) were planned and 78 of 122 (63.9%) were unplanned. A majority of unplanned readmissions (57 of 78; 73%) were related to interventional radiology. Of unplanned interventional radiology-related readmissions, 16% (nine of 57) were related to periprocedural complications and 51% (29 of 57) were considered preventable. At multivariable analysis, Medicaid insurance (odds ratio, 3.68; 95% confidence interval: 1.52, 9.99; P = .009) and bilateral PTBDs (odds ratio, 5.81; 95% confidence interval: 1.79, 18.90; P = .003) were associated with 30-day readmission. Conclusion Thirty-day readmissions after primary biliary drainage are common and a majority of unplanned readmissions are drain-related. Nearly half of unplanned interventional radiology-related readmissions are potentially preventable. © RSNA, 2018 See also the editorial by Nikolic in this issue.


Assuntos
Neoplasias dos Ductos Biliares/terapia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Radiografia Intervencionista , Idoso , Neoplasias dos Ductos Biliares/diagnóstico por imagem , Boston/epidemiologia , Colangiografia , Drenagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
19.
J Orthop Res ; 37(1): 190-196, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30273986

RESUMO

The purpose was to assess the incidence and risk factors associated with symptomatic venous thromboembolism in patients undergoing below knee immobilization for non-operative foot or ankle injury. We included all foot and ankle patients between January 2005 and May 2016 who underwent non-operative management using below knee immobilization with cast, splint, brace, and/or boot. The primary outcome was the development of a venous thromboembolism within 90 days of immobilization initiation. Of 6,088 patients, twenty-three (0.38%) developed a venous thromboembolism. Risk factors for venous thromboembolism were age>50 years, unremovable immobilization, Achilles tendon rupture, Modified Charlson Comorbidity Index>2, patients on chemoprophylaxis, varicose veins, history of venous thromboembolism, known hypercoagulability disorder, and rheumatoid arthritis. Routine thromboprophylaxis after below-knee immobilization for non-operative foot or ankle injury may be beneficial in these specific subpopulations. These data can facilitate more substantive shared decision-making between providers and patients with respect to use of thromboprophylaxis. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.


Assuntos
Traumatismos do Tornozelo/terapia , Traumatismos do Pé/terapia , Imobilização/efeitos adversos , Tromboembolia Venosa/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Boston/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Tromboembolia Venosa/etiologia , Adulto Jovem
20.
J Gerontol A Biol Sci Med Sci ; 74(6): 924-928, 2019 05 16.
Artigo em Inglês | MEDLINE | ID: mdl-30010808

RESUMO

BACKGROUND: The Lifestyle Interventions and Independence for Elders (LIFE) clinical trial demonstrated that a structured program of physical activity (PA) reduced mobility-disability in older adults by up to 28%. It remains unknown whether the benefits of LIFE PA can be translated to older adults at risk for mobility-disability in real-world community-based settings. To address this knowledge gap, we conducted the ENhancing independence using Group-based community interventions for healthy AGing in Elders (ENGAGE) pilot study and examined the safety, feasibility, and preliminary effectiveness of translating LIFE PA to a community-based senior center. METHODS: Forty older adults with severe lower extremity functional limitations (age: 76.9 ± 7.3 years; body mass index: 32.7 ± 8 kg/m2; 85% female; short physical performance battery score: 6.3 ± 2.2) were randomized to 24 weeks of PA or a health education control intervention. RESULTS: Community-based PA was safe (serious adverse events: PA vs health education, 0:2; nonserious adverse events: PA vs health education, 3:1) and participants successfully adhered to the PA intervention (65.2%). Compared to health education, PA participants who attended ≥25% of scheduled visits had meaningful and sustained short physical performance battery improvements at follow-up (between group short physical performance battery score differences: ~0.7 units). CONCLUSIONS: ENGAGE has demonstrated the preliminary safety, feasibility, and effectiveness of LIFE PA in a real-world community-based setting. Larger-scale translational studies are needed to further disseminate the benefits of LIFE PA to vulnerable older adults in a variety of community-based settings.


Assuntos
Exercício , Promoção da Saúde , Envelhecimento Saudável , Estilo de Vida , Acidentes por Quedas/prevenção & controle , Acidentes por Quedas/estatística & dados numéricos , Idoso , Boston/epidemiologia , Depressão/terapia , Função Executiva , Estudos de Viabilidade , Feminino , Humanos , Masculino , Limitação da Mobilidade , Desempenho Físico Funcional , Projetos Piloto , Qualidade de Vida , Método Simples-Cego , População Urbana
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