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1.
Surg Clin North Am ; 99(6): 1141-1150, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31676053

RESUMO

Although improved medical therapies have been associated with decreased rates of emergent intestinal resection for inflammatory bowel disease, prompt diagnosis and management remain of utmost importance to ensure appropriate patient care with reduced morbidity and mortality. Emergent indications for surgery include toxic colitis, acute obstruction, perforation, acute abscess, or massive hemorrhage. Given this broad spectrum of emergent presentations, a multidisciplinary team including surgeons, gastroenterologists, radiologists, nutritional support services, and enterostomal therapists are required for optimal patient care and decision making. Management of each emergency should be individualized based on patient age, disease type and duration, and patient goals of care.


Assuntos
Colectomia/métodos , Hemorragia Gastrointestinal/cirurgia , Doenças Inflamatórias Intestinais/complicações , Obstrução Intestinal/cirurgia , Perfuração Intestinal/etiologia , Perfuração Intestinal/cirurgia , Abdome Agudo/etiologia , Abdome Agudo/cirurgia , Anastomose Cirúrgica , Colite Ulcerativa/complicações , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/terapia , Doença de Crohn/complicações , Doença de Crohn/diagnóstico , Doença de Crohn/terapia , Emergências , Feminino , Hemorragia Gastrointestinal/etiologia , Humanos , Doenças Inflamatórias Intestinais/diagnóstico , Obstrução Intestinal/etiologia , Obstrução Intestinal/fisiopatologia , Perfuração Intestinal/fisiopatologia , Masculino , Equipe de Assistência ao Paciente/organização & administração , Prognóstico , Medição de Risco , Resultado do Tratamento
2.
In Vivo ; 33(2): 523-528, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30804136

RESUMO

AIM: The aim was to analyze the correlation between psoas muscle mass and mortality, as well as postoperative complications in patients treated for colonic perforation. PATIENTS AND METHODS: A total of 46 patients met the study criteria. Patients were classified into an elderly (age, ≥75 years, n=24) and a younger group (age, <75 years, n=22). Background factors, postoperative data (including duration of hospital stay and discharge) were collected. The cross-sectional area of the psoas muscle area (PMA) was measured on the same day of operation. RESULTS: The age/length of stay and PMA were significantly correlated in the younger group (p=0.0015, 0.023, respectively). Fifteen and six patients were discharged to return home, and 8 and 16 patients were transferred to another hospital, in the younger and elderly groups, respectively (p=0.02). Discharge was not correlated with the PMA in either group. CONCLUSION: The total psoas muscle mass would be useful as a quick and convenient measure of sarcopenia in younger patients, but not elderly patients.


Assuntos
Neoplasias do Colo/cirurgia , Músculo Esquelético/cirurgia , Sarcopenia/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias do Colo/diagnóstico por imagem , Neoplasias do Colo/patologia , Neoplasias do Colo/fisiopatologia , Estudos Transversais , Feminino , Humanos , Perfuração Intestinal/fisiopatologia , Perfuração Intestinal/cirurgia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/diagnóstico por imagem , Músculo Esquelético/fisiopatologia , Músculos Psoas/diagnóstico por imagem , Músculos Psoas/fisiopatologia , Músculos Psoas/cirurgia , Estudos Retrospectivos , Sarcopenia/diagnóstico por imagem , Sarcopenia/fisiopatologia , Tomografia Computadorizada por Raios X
5.
JNMA J Nepal Med Assoc ; 56(210): 625-628, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30376009

RESUMO

Trekkers going to high altitude can suffer from several ailments both during and after their treks. Gastro-intestinal symptoms including nausea, vomiting, and abdominal pain are common in high altitude areas of Nepal due to acute mountain sickness or due to a gastro-intestinal illness. Occasionally, complications of common conditions manifest at high altitude and delay in diagnosis could be catastrophic for the patient presenting with these symptoms. We present two rare cases of duodenal and gastric perforations in trekkers who were evacuated from the Everest trekking region. Both of them had to undergo emergency laparotomy and repair of the perforation using modified Graham's patch in the first case and distal gastrectomy that included the perforated site, followed by two-layer end-to-side gastrojejunostomy and two-layer side-to-side jejunostomy in the second case. Perforation peritonitis at high-altitude, though rare, can be life threatening. Timely evacuation from high altitude, proper diagnosis and prompt treatment are essential for taking care of such patients. Keywords: duodenal ulcer; Everest; hypoxia; mountaineering; trekking.


Assuntos
Abdome Agudo , Altitude , Duodeno , Gastrectomia/métodos , Perfuração Intestinal , Montanhismo , Ruptura Gástrica , Abdome Agudo/diagnóstico , Abdome Agudo/etiologia , Idoso , Diagnóstico Diferencial , Duodeno/diagnóstico por imagem , Duodeno/cirurgia , Derivação Gástrica/métodos , Humanos , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/fisiopatologia , Perfuração Intestinal/cirurgia , Laparotomia/métodos , Masculino , Pessoa de Meia-Idade , Nepal , Ruptura Gástrica/diagnóstico por imagem , Ruptura Gástrica/fisiopatologia , Ruptura Gástrica/cirurgia , Resultado do Tratamento
7.
Am J Perinatol ; 35(8): 774-778, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29298457

RESUMO

INTRODUCTION: Necrotizing enterocolitis (NEC) is a devastating disease of infancy. Full-thickness bowel wall necrosis may lead to perforation, peritonitis, and death. Timeous clinical diagnosis of impending perforation is imperative. OBJECTIVE: The objective of this study was to determine whether a persistent tachycardia in an infant with proven NEC is indicative of full-thickness bowel wall necrosis and therefore impending perforation. STUDY DESIGN: This study was conducted at the University of Pretoria academic hospitals. Forty-five neonates with proven NEC were divided into a surgical group (32 progressed to full-thickness bowel necrosis) and a nonsurgical group (13 resolved on conservative treatment). Differences in the pulse rate between the groups were analyzed. RESULTS: The 24-hour leading average pulse rate data for the surgical group were analyzed over a period of 10 days leading up to surgery and compared with the nonsurgical group. A clear upward trend of the mean pulse rate was observed in the surgical group, 48 hours prior to surgery. This was statistically significant (p < 0.05). CONCLUSION: This study demonstrated that a persistent tachycardia in a neonate with NEC is a predictor of progression to full-thickness bowel wall necrosis. Pulse rate is therefore an important clinical tool when deciding on operative management in NEC.


Assuntos
Enterocolite Necrosante/fisiopatologia , Frequência Cardíaca , Perfuração Intestinal/fisiopatologia , Taquicardia/diagnóstico , Progressão da Doença , Enterocolite Necrosante/complicações , Enterocolite Necrosante/cirurgia , Feminino , Humanos , Recém-Nascido , Perfuração Intestinal/complicações , Perfuração Intestinal/cirurgia , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Taquicardia/etiologia
9.
Ann R Coll Surg Engl ; 99(5): e154-e155, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28462643

RESUMO

Haemorrhoidal artery ligation has now been established as a treatment modality for symptomatic haemorrhoids. We report a case of a fit 44-year-old male who underwent the procedure as a day case, who subsequently developed pelvic sepsis due to rectal perforation. This case is the first report of a potentially life-threatening complication resulting from this procedure, which has a previously excellent safety profile.


Assuntos
Canal Anal/cirurgia , Hemorroidas/cirurgia , Perfuração Intestinal , Ligadura/efeitos adversos , Complicações Pós-Operatórias , Adulto , Humanos , Perfuração Intestinal/diagnóstico por imagem , Perfuração Intestinal/fisiopatologia , Perfuração Intestinal/terapia , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia
11.
Surg Today ; 47(1): 114-121, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27262675

RESUMO

PURPOSE: Anastomotic leakage is a major postoperative complication. While cell sheet technology has been gaining popularity in the clinical field, the utility of cell sheets for containing contaminated enteral perforation remains unclear. We established a new gastric perforation rat model and evaluated the efficacy of the myoblast cell sheet to prevent leakage. METHODS: To establish a suitable rat model, perforations of various sizes were made in the stomach. We then pasted the sheet onto the perforated stomach in our new model. After the operation, the rats were sacrificed and analyzed macroscopically and histologically. Serum levels of C-related protein and hyaluronic acid in the peritoneal cavity washing lavage were also evaluated. RESULTS: An incision 5 mm in length was found to be the most suitable for evaluation of the cell sheet performance. In the rats where the cell sheet had been pasted onto the perforation site, we noted less adhesion in the abdominal cavity and a significant reduction in the hyaluronic acid levels in the peritoneal cavity washing lavage. CONCLUSIONS: We evaluated the efficacy of cell sheets for preventing leakage of enteral contents in a gastric perforation rat model. Myoblast cell sheets were able to markedly reduce the degree of both intra-abdominal adhesion and inflammation.


Assuntos
Técnicas Citológicas/métodos , Trato Gastrointestinal/citologia , Trato Gastrointestinal/fisiologia , Perfuração Intestinal/patologia , Perfuração Intestinal/fisiopatologia , Mioblastos/fisiologia , Regeneração/fisiologia , Medicina Regenerativa/métodos , Animais , Células Cultivadas , Modelos Animais de Doenças , Masculino , Ratos Sprague-Dawley
12.
Fetal Diagn Ther ; 42(1): 57-62, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-27649500

RESUMO

OBJECTIVE: To identify the fetal and neonatal imaging characteristics of meconium peritonitis (MP) and their clinical outcome. We also studied the role of prenatal ultrasound (US) in antenatal diagnosis and its use in predicting the need for surgical intervention postnatally. MATERIAL AND METHODS: We conducted a retrospective analysis of a cohort of 18 infants with MP from April 2004 to March 2014. RESULTS: Prenatal US detected MP-related abnormalities in 15/18 (83.3%) fetuses. The median gestational age at initial diagnosis of MP was 24 weeks (range 19-31). Fetal ascites (93.3%) was the most common prenatal US finding. Of the 18 infants, 12 (66.7%) required surgical intervention. The overall survival rate was 94.4%. All infants with a prenatal US scan showing meconium pseudocyst or bowel dilatation required surgical intervention postnatally. DISCUSSION: A combination of ascites, intraperitoneal calcification, and echogenic bowel on fetal US raises a high suspicion of MP. Surgical intervention is indicated in the presence of meconium pseudocyst on fetal or postnatal US scan. Antenatal US has high specificity (100%) but low sensitivity (22.2%) in detecting meconium pseudocyst. A favorable outcome can be expected with early antenatal diagnosis and timely surgical intervention in a tertiary hospital.


Assuntos
Anormalidades do Sistema Digestório/fisiopatologia , Perfuração Intestinal/fisiopatologia , Intestino Delgado/anormalidades , Mecônio , Peritonite/diagnóstico por imagem , Ultrassonografia Pré-Natal , Ascite/diagnóstico por imagem , Ascite/embriologia , Ascite/etiologia , Ascite/prevenção & controle , Estudos de Coortes , Terapia Combinada/efeitos adversos , Anormalidades do Sistema Digestório/cirurgia , Feminino , Seguimentos , Idade Gestacional , Humanos , Incidência , Recém-Nascido , Perfuração Intestinal/cirurgia , Intestino Delgado/cirurgia , Masculino , Peritonite/embriologia , Peritonite/epidemiologia , Peritonite/etiologia , Complicações Pós-Operatórias/prevenção & controle , Gravidez , Prognóstico , Estudos Retrospectivos , Singapura/epidemiologia , Análise de Sobrevida
13.
Pol Przegl Chir ; 88(3): 142-6, 2016 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-27428835

RESUMO

UNLABELLED: Acute appendicitis (AA) still remains the most common acute surgical abdominal emergency. Although 90% of cases occur in children and young adults, the incidence in the elderly amounts up to 10% and is constantly rising. The aim of the study was to assess the differences between clinical presentation in the elderly patients with AA compared to the younger patients. Additional aim was to assess the correlation between in-hospital time delays and patients' outcomes. MATERIAL AND METHODS: We conducted a retrospective analysis of medical data of 274 patients admitted to 3rd Department of General Surgery in Cracow between January 2011 and December 2013 due to AA. The elderly group comprised 23 patients aged 65 and above and the non-elderly group consisted of 251 patients. RESULTS: The groups did not differ in symptoms and their duration, type of surgery and its duration. However, time from admission to ED to the beginning of the procedure was significantly lower in the elderly group (575.56 vs 858.9 min; p=0.03). The elderly had longer hospital stay (6.08 vs 4.69 days; p=0.004). In the elderly group the perforation rate was close to reaching statistical significance (26.1% vs 12.4%; p=0.06). No mortality was noted in both groups and morbidity was slightly higher in elderly group (17.4% vs 10%; p=0.26). CONCLUSIONS: There was no difference in the clinical presentation between elderly and non-elderly patients group. However, elderly patients presented with a more progressed inflammation of the appendix. The hospital stay was longer in the elderly group, without any mortality and with higher rate of morbidity in this group. The length of the preoperative phase was significantly shorter, confirming the awareness of importance of time in the elderly patients with acute abdomen.


Assuntos
Apendicectomia , Apendicite/diagnóstico , Apendicite/fisiopatologia , Perfuração Intestinal/fisiopatologia , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/fisiopatologia , Doença Aguda , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Apendicite/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Polônia , Estudos Retrospectivos , Adulto Jovem
14.
Dis Colon Rectum ; 59(4): 332-9, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26953992

RESUMO

BACKGROUND: The indications for interval elective colectomy following diverticulitis are unclear; evidence lends increasing support for nonoperative management. OBJECTIVE: This study aims to evaluate the temporal trends in the use of elective colectomy following diverticulitis. DESIGN: This is a population-based retrospective cohort study using administrative discharge data. SETTING: This study was conducted in Ontario, Canada. PATIENTS: Patients who had had an episode of diverticulitis managed nonoperatively and were eligible for elective colectomy, from 2002 to 2012, were selected. MAIN OUTCOME MEASURES: Changes in the proportion of patients who undergo elective colectomy following an episode of diverticulitis treated nonoperatively were evaluated. Cochran-Armitage was used to test for trends; adjusted analysis was performed by using multivariable logistic regression with generalized estimating equations. RESULTS: A total of 14,124 patients were admitted with an episode of diverticulitis and treated nonoperatively, making them eligible for interval elective colectomy. Median follow-up was 3.9 years (maximum, 10; interquartile range, 1.7-6.4). Overall, 1342 (9.5%) patients underwent elective colectomy; 33% of these colectomies were performed laparoscopically, and 7.5% patients received an ostomy. In-hospital mortality was 0.2%. The majority (76%) of elective operations were performed within 1 year of discharge (median, 160 days; interquartile range, 88-346). The proportion of patients undergoing elective colectomy within 1 year of discharge declined from 9.6% of patients in 2002 to 3.9% by 2011 (p < 0.001). The decline was most pronounced in patients <50 years of age (from 17% to 5%), and those with complicated disease (from 28% to 8%) (all p < 0.001). In multivariable regression, younger age, lower medical comorbidity, complicated disease, and early readmission were associated with elective colectomy. After adjusting for changes in patient characteristics, the odds of elective surgery decreased by 0.93 per annum (adjusted OR; 95% CI, 0.90-0.95). LIMITATIONS: Administrative health databases contain limited clinical detail; the rationale for elective surgery was not available. CONCLUSIONS: Consistent with evolving practice guidelines, there has been a decrease in the use of elective colectomy following an episode of diverticulitis.


Assuntos
Abscesso Abdominal/fisiopatologia , Colectomia/tendências , Colostomia/tendências , Doença Diverticular do Colo/cirurgia , Procedimentos Cirúrgicos Eletivos/tendências , Perfuração Intestinal/fisiopatologia , Laparoscopia/tendências , Abscesso Abdominal/complicações , Adulto , Fatores Etários , Idoso , Estudos de Coortes , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/fisiopatologia , Feminino , Mortalidade Hospitalar , Humanos , Perfuração Intestinal/complicações , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Ontário , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença
15.
J Paediatr Child Health ; 52(3): 272-7, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26515522

RESUMO

AIM: In view of recent studies questioning the usefulness of peritoneal drainage (PD) in premature neonates with pneumoperitoneum, suggesting approximately 75% of those treated with PD needed delayed laparotomy, we reviewed the requirement for laparotomy after initial PD at our institution. METHODS: Retrospective cohort of all premature infants with a diagnosis of intestinal perforation (ICD Code P78.0) from 1995 to 2012. Inclusion criteria were pneumoperitoneum on x-ray (isolated perforation or necrotising enterocolitis), birthweight <1800 g and gestational age <33 weeks. RESULTS: Fifty patients met the criteria (38 PD, 12 primary laparotomy). Thirty-two per cent (95% CI 18-49%) received secondary laparotomy after initial PD. There was no significant difference when stratified according to isolated perforation (24%) versus necrotising enterocolitis (56%, P = 0.11). There was no significant difference between PD and primary laparotomy for time to full enteral nutrition, hazard ratio (HR) 0.99 (95% CI 0.48-2.04) or mortality, HR 2.15 (95% CI 0.48-9.63). The HR for mortality was partly confounded by birthweight, birthweight-adjusted HR 1.52 (95% CI 0.32-7.23). CONCLUSIONS: Thirty-two per cent of neonates treated with primary PD received secondary laparotomy, with no significant difference in key outcomes. Primary PD still appears to be of benefit for those without features of necrotising enterocolitis.


Assuntos
Drenagem/métodos , Enterocolite Necrosante/cirurgia , Recém-Nascido Prematuro , Perfuração Intestinal/cirurgia , Laparotomia/métodos , Estudos de Coortes , Terapia Combinada , Intervalos de Confiança , Bases de Dados Factuais , Drenagem/mortalidade , Enterocolite Necrosante/complicações , Enterocolite Necrosante/diagnóstico , Feminino , Humanos , Recém-Nascido , Doenças do Prematuro/diagnóstico , Doenças do Prematuro/mortalidade , Doenças do Prematuro/cirurgia , Recém-Nascido de muito Baixo Peso , Unidades de Terapia Intensiva Neonatal , Perfuração Intestinal/etiologia , Perfuração Intestinal/mortalidade , Perfuração Intestinal/fisiopatologia , Laparotomia/mortalidade , Masculino , Determinação de Necessidades de Cuidados de Saúde , Nova Zelândia , Pneumoperitônio/diagnóstico , Pneumoperitônio/cirurgia , Prognóstico , Estudos Retrospectivos , Medição de Risco , Taxa de Sobrevida , Resultado do Tratamento
16.
Gastrointest Endosc ; 80(4): 717-722, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25085337

RESUMO

BACKGROUND: GI perforations occur rarely during endoscopy but have life-threatening implications. OBJECTIVE: To evaluate endoscopic band ligation (EBL) for closure of acute GI perforations by using a porcine model. DESIGN: Investigator-initiated interventional pilot study by using an in vivo porcine model. SETTING: Tertiary-care institution. SUBJECTS: Ten domestic pigs. INTERVENTION: Each animal underwent a single endoscopic procedure, with creation of a single GI lumen perforation. Perforations of 10 to 20 mm were created in the esophagus, stomach, duodenum, and colon. EBL was used for closure. Fourteen days later, the pigs were killed, microbial cultures were obtained, and histologic review was done. MAIN OUTCOME MEASUREMENTS: Immediate and delayed endoscopic closure of the perforation site, evidence of clinical peritonitis during the 14-day follow-up. RESULTS: Ten pigs completed the protocol and survived without clinical peritonitis during the 14-day follow-up. Endoscopic closure of a 15-mm esophageal perforation failed, thus, no attempt was made to close a 20-mm esophageal perforation. Closure of all other perforations was successful. At necropsy, fibrinous peritonitis was suspected in one animal with a 10-mm duodenal perforation. Chronic inflammation and fibroplasia at the perforation sites were the most common histologic findings. LIMITATIONS: The applicability of widespread use in humans remains unknown despite successful case reports in the medical literature. CONCLUSION: EBL can be used successfully to close 10 to 20 mm perforations within normal stomach, duodenum, and colon and can prevent clinically relevant intra-abdominal infections. However, for esophageal perforations, closure may be limited to small (≤10 mm), iatrogenic perforations.


Assuntos
Endoscopia Gastrointestinal/métodos , Perfuração Esofágica/cirurgia , Perfuração Intestinal/cirurgia , Animais , Doenças do Colo/cirurgia , Modelos Animais de Doenças , Duodenopatias/cirurgia , Perfuração Esofágica/fisiopatologia , Perfuração Intestinal/fisiopatologia , Ligadura/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Projetos Piloto , Sensibilidade e Especificidade , Sus scrofa , Gravação em Vídeo
17.
Clin Exp Rheumatol ; 32(3 Suppl 82): S73-5, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24854375

RESUMO

Viral vasculitides have been previously reported in the literature, the role of infections in their pathogenesis ranging from direct cause to trigger event. Here we report the case of a 3-year-old immunocompetent girl who developed a systemic vasculitis leading to ileal perforation, mimicking a full blown picture of Henoch-Schönlein purpura. High dosage steroid treatment was started, with good response. The anatomopathological examination of the resected gastrointestinal tract showed features of necrotising vasculitis and cytomegalovirus (CMV)-related inclusion bodies in the endothelial cells, with direct correlation to vascular damage. The causative role of viral infection was revealed by the presence of CMV DNA in patient's blood and positive IgG titer against the virus. Steroid therapy was then tapered: the patient achieved clinical remission, which still persists after a six-months follow-up. Our report suggests that CMV vasculitis is probably more frequent than previously thought, even in immunocompetent patients, with a protean clinical presentation, mimicking other types of vasculitides.


Assuntos
Infecções por Citomegalovirus/complicações , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Doenças do Íleo/etiologia , Íleo , Perfuração Intestinal/etiologia , Metilprednisolona/administração & dosagem , Púrpura de Schoenlein-Henoch/diagnóstico , Vasculite Sistêmica , Pré-Escolar , Citomegalovirus/isolamento & purificação , Infecções por Citomegalovirus/fisiopatologia , Infecções por Citomegalovirus/virologia , Diagnóstico Diferencial , Esquema de Medicação , Feminino , Glucocorticoides/administração & dosagem , Humanos , Doenças do Íleo/diagnóstico , Doenças do Íleo/fisiopatologia , Doenças do Íleo/cirurgia , Íleo/patologia , Íleo/cirurgia , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/fisiopatologia , Perfuração Intestinal/cirurgia , Monitorização Imunológica , Indução de Remissão , Vasculite Sistêmica/diagnóstico , Vasculite Sistêmica/tratamento farmacológico , Vasculite Sistêmica/etiologia , Vasculite Sistêmica/fisiopatologia , Resultado do Tratamento
20.
J Pediatr Gastroenterol Nutr ; 56(6): e41, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22395186
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