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1.
Medicine (Baltimore) ; 98(38): e17034, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31567940

RESUMO

BACKGROUND: Pericardial infection caused by Acinetobacter baumannii is rare, particularly that of carbapenem-resistant A baumannii (CRAB). CASE PRESENTATION: We describe a rare case of purulent pericarditis due to CRAB in a 76-year-old man with acute myocardial infarction and acute kidney injury. The man was admitted to the intensive care unit for a catheter-related bloodstream infection. Pericardial effusion was detected via the bedside X-ray and ultrasound, and pericardiocentesis was performed. Cultures of the pericardial fluid, catheter tip, and blood independently revealed the presence of CRAB. These findings confirmed a diagnosis of purulent pericarditis. CONCLUSIONS: Clinicians should be reminded that CRAB infection can lead to purulent pericarditis, particularly in patients with congestive heart failure or renal insufficiency.


Assuntos
Infecções por Acinetobacter/diagnóstico , Acinetobacter baumannii/isolamento & purificação , Lesão Renal Aguda/diagnóstico , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Pericardite/diagnóstico , Infecções por Acinetobacter/complicações , Acinetobacter baumannii/efeitos dos fármacos , Lesão Renal Aguda/complicações , Idoso , Carbapenêmicos/farmacologia , Diagnóstico Diferencial , Farmacorresistência Bacteriana , Evolução Fatal , Humanos , Masculino , Infarto do Miocárdio sem Supradesnível do Segmento ST/complicações , Pericardiocentese , Pericardite/complicações , Pericardite/diagnóstico por imagem , Tomografia Computadorizada por Raios X
3.
Braz J Cardiovasc Surg ; 34(2): 194-202, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30916130

RESUMO

OBJECTIVE: In this retrospective study, we aimed to observe the efficacy of pericardial effusion (PE) treatments by a survey conducted at the Department of Cardiovascular Surgery, Faculty of Medicine, Atatürk University. METHODS: In order to get comparable results, the patients with PE were divided into three groups - group A, 480 patients who underwent subxiphoid pericardiostomy; group B, 28 patients who underwent computerized tomography (CT)-guided percutaneous catheter drainage; and group C, 45 patients who underwent echocardiography (ECHO)-guided percutaneous catheter drainage. RESULTS: In the three groups of patients, the most important symptom and physical sign were dyspnea and tachycardia, respectively. The most common causes of PE were uremic pericarditis in patients who underwent tube pericardiostomy, postoperative PE in patients who underwent CT-guided percutaneous catheter drainage, and cancer-related PE in patients who underwent ECHO-guided percutaneous catheter drainage. In all the patients, relief of symptoms was achieved after surgical intervention. There was no treatment-related mortality in any group of patients. In patients with tuberculous pericarditis, the rates of recurrent PE and/or constrictive pericarditis progress were 2,9% and 2,2% after tube pericardiostomy and ECHO-guided percutaneous catheter drainage, respectively. CONCLUSION: Currently, there are many methods to treat PE. The correct treatment method for each patient should be selected according to a very careful analysis of the patient's clinical condition as well as the prospective benefit of surgical intervention.


Assuntos
Cateterismo Cardíaco/métodos , Drenagem/métodos , Ecocardiografia/métodos , Derrame Pericárdico/cirurgia , Técnicas de Janela Pericárdica , Tomografia Computadorizada por Raios X/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Cateterismo Cardíaco/instrumentação , Criança , Pré-Escolar , Drenagem/instrumentação , Ecocardiografia/instrumentação , Feminino , Humanos , Lactente , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/etiologia , Técnicas de Janela Pericárdica/instrumentação , Pericardite/complicações , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo , Tomografia Computadorizada por Raios X/instrumentação , Resultado do Tratamento , Adulto Jovem
4.
Rev Port Cardiol ; 38(2): 97-101, 2019 02.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30876791

RESUMO

INTRODUCTION: Pericarditis is an inflammation of the pericardium. It may be infectious or secondary to a systemic disease. The aim of this study was to analyze the clinical findings, course, treatment and follow-up of children diagnosed with pericarditis at our center. METHODS: We performed a retrospective analysis of all children admitted to our pediatric cardiology unit with pericarditis between 2003 and 2015. Patient characteristics were summarized using frequencies and percentages for categorical variables and medians with percentiles for continuous variables. RESULTS: Fifty patients were analyzed (40 male, 10 female) with a median age of 14 years. The most common diagnosis was acute pericarditis (80%). Thirty-five patients (70%) presented with chest pain and 26% reported fever. Cardiomegaly was identified on chest X-ray in 11 patients (22%), 30 patients (60%) had an abnormal ECG and 44 patients (80%) had alterations on the transthoracic echocardiogram. In 17 cases (34%) there was myocardial involvement. Forty-eight percent of patients presented with infectious pericarditis and the pathologic agent was identified in half of them. Postpericardiotomy syndrome was diagnosed in five cases. The first-line therapy was aspirin in 50% of cases. Pericardiocentesis was performed in 12 patients. The median length of stay was nine days. There was symptom recurrence in seven children. CONCLUSIONS: In this study, acute infectious pericarditis was the most common presentation and about one third of patients also had myocarditis. The symptom recurrence rate was not negligible and is probably related to the type of therapy employed.


Assuntos
Ecocardiografia/métodos , Pericardite/diagnóstico , Pericárdio/diagnóstico por imagem , Doença Aguda , Adolescente , Criança , Eletrocardiografia , Feminino , Seguimentos , Humanos , Masculino , Derrame Pericárdico/diagnóstico , Derrame Pericárdico/etiologia , Derrame Pericárdico/cirurgia , Pericardiocentese , Pericardite/complicações , Recidiva , Estudos Retrospectivos
5.
Intern Emerg Med ; 14(5): 745-751, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30868443

RESUMO

The clinical significance of pleural effusions (PLEs) in the setting of acute pericarditis remains poorly investigated. We sought to identify predictive factors for PLEs and their association with the short- and long-term prognosis of patients with acute pericarditis. We enrolled 177 patients hospitalized with a first episode of acute pericarditis. In all cases an extensive clinical, biochemical, and diagnostic work-up to detect PLEs and establish etiological diagnosis was performed. All patients included were prospectively followed for a maximum of 18 months (median 12, range 1-18) and complications were recorded. PLEs were detected in n = 94 cases (53.1% of the cohort; bilateral 53.2%, left-sided 28.7%, right-sided 18.1%) and were strongly associated with c-reactive protein (CRP) levels at admission (rho = 0.328, p < 0.001). In multivariate logistic regression, independent predictors for PLEs were female gender (OR = 2.46, 95% CI 1.03-5.83), age (per 1-year increment OR = 1.030, 95% CI 1.005-1.056), CRP levels (per 1 mg/L increment OR = 1.012, 95% CI 1.006-1.019) and size of pericardial effusion (per 1 cm increment, OR = 1.899, 95% CI 1.228-2.935). Bilateral PLEs were associated with increased risk for in-hospital cardiac tamponade (OR = 7.52, 95% CI 2.16-26.21). There was no association of PLEs with new onset atrial fibrillation or pericarditis recurrence during long-term follow-up (χ2 = 0.003, p = 0.958). We conclude that PLEs are common in patients hospitalized with a first episode of acute pericarditis. They are related to the intensity of inflammatory reaction, and they should not be considered necessarily as a marker of secondary etiology. Bilateral PLEs are associated with increased risk of in-hospital cardiac tamponade, but do not affect the long-term risk of pericarditis recurrence.


Assuntos
Pericardite/complicações , Derrame Pleural/etiologia , Adulto , Análise de Variância , Ecocardiografia/métodos , Feminino , Grécia , Hospitalização/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pericardite/fisiopatologia , Derrame Pleural/fisiopatologia , Modelos de Riscos Proporcionais , Estudos Prospectivos , Resultado do Tratamento
7.
Ann Thorac Surg ; 107(1): e27-e29, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29932888

RESUMO

A 58-year-old man presented with tamponade and underwent an emergency pericardiocentesis. We made the diagnosis of methicillin-resistant Staphylococcus aureus pericarditis based on culture results and treated the patient with pericardial drainage and antibiotics as the first-line therapy. After temporary relief, reaccumulation of effusion developed. We successfully created a pericardial window using thoracotomy, and the patient's postoperative course was uneventful. Methicillin-resistant Staphylococcus aureus pericarditis is an extremely rare and life-threatening illness. No consensus exists concerning the ideal surgical intervention. Creating a pericardial window using thoracotomy can be an effective definitive therapy for methicillin-resistant Staphylococcus aureus pericarditis, especially for patients with significant pericardial adhesions.


Assuntos
Tamponamento Cardíaco/etiologia , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Técnicas de Janela Pericárdica , Pericardite/cirurgia , Infecções Estafilocócicas/cirurgia , Antibacterianos/uso terapêutico , Tamponamento Cardíaco/diagnóstico por imagem , Tamponamento Cardíaco/cirurgia , Terapia Combinada , Quimioterapia Combinada , Ecocardiografia , Emergências , Humanos , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/diagnóstico por imagem , Derrame Pericárdico/etiologia , Líquido Pericárdico/microbiologia , Pericardiocentese , Pericardite/complicações , Pericardite/tratamento farmacológico , Pericardite/microbiologia , Diálise Renal , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/terapia , Infecções Estafilocócicas/complicações , Infecções Estafilocócicas/tratamento farmacológico , Infecções Estafilocócicas/microbiologia , Tomografia Computadorizada por Raios X , Dispositivos de Acesso Vascular/efeitos adversos
8.
Heart ; 105(6): 477-481, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30274986

RESUMO

OBJECTIVE: Aim of this paper is to evaluate the outcomes of 'idiopathic' chronic large pericardial effusions without initial evidence of pericarditis. METHODS: All consecutive cases of idiopathic chronic large pericardial effusions evaluated from 2000 to 2015 in three Italian tertiary referral centres for pericardial diseases were enrolled in a prospective cohort study. The term 'idiopathic' was applied to cases that performed a complete diagnostic evaluation to exclude a specific aetiology. A clinical and echocardiographic follow-up was performed every 3-6 months. RESULTS: 100 patients were included (mean age 61.3±14.6 years, 54 females, 44 patients were asymptomatic according to clinical evaluation) with a mean follow-up of 50 months. The baseline median size of the effusion (evaluated as the largest end-diastolic echo-free space) was 25 mm (IQR 8) and decreased to a mean value of 7 mm (IQR 19; p<0.0001) with complete regression in 39 patients at the end of follow-up. There were no new aetiological diagnoses. Adverse events were respectively: cardiac tamponade in 8 patients (8.0%), pericardiocentesis in 30 patients (30.0%), pericardial window in 12 cases (12.0%) and pericardiectomy in 3 patients (3.0%). Recurrence-free survival and complications-free survival was better in patients treated without interventions (log rank p=0.0038). CONCLUSIONS: The evolution of 'idiopathic' chronic large pericardial effusions is usually benign with reduction of the size of the effusion in the majority of cases, and regression in about 40% of cases. The risk of cardiac tamponade is 2.2%/year and recurrence/complications survival was better in patients treated conservatively without interventions.


Assuntos
Doenças Assintomáticas/epidemiologia , Tamponamento Cardíaco , Derrame Pericárdico , Pericardiectomia , Pericardiocentese , Pericardite , Idoso , Tamponamento Cardíaco/diagnóstico , Tamponamento Cardíaco/epidemiologia , Tamponamento Cardíaco/etiologia , Ecocardiografia/métodos , Feminino , Seguimentos , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/complicações , Derrame Pericárdico/diagnóstico , Derrame Pericárdico/epidemiologia , Pericardiectomia/métodos , Pericardiectomia/estatística & dados numéricos , Pericardiocentese/métodos , Pericardiocentese/estatística & dados numéricos , Pericardite/complicações , Pericardite/diagnóstico , Pericardite/epidemiologia , Estudos Prospectivos , Recidiva , Fatores de Risco , Índice de Gravidade de Doença , Análise de Sobrevida
10.
J Coll Physicians Surg Pak ; 28(12): 972-973, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30501839

RESUMO

We herein report a case of late diagnosed thoracic esophageal perforation. A 60-year-old man was diagnosed as an esophageal perforation with mediastinitis and pericardial abscess by detailed history taking, chest computed tomography, esophagoscopy and inflammatory findings in his blood test. Surgical drainage of mediastinum and pericardium was able to effectively control infectious process and pericardial fibrosis. Endoscopic esophageal stent placement on the thoracic- esophageal fistula promoted healing of the esophageal wall defect and enabled him to restart oral intake. This case report suggests that detailed history taking is important for all patients. Effective drainage of mediastinum and the use of esophageal stent may be the treatment options for late-diagnosed esophageal perforation.


Assuntos
Abscesso/diagnóstico , Diagnóstico Tardio , Perfuração Esofágica/diagnóstico , Mediastinite/diagnóstico , Pericardite/diagnóstico , Abscesso/complicações , Abscesso/cirurgia , Perfuração Esofágica/complicações , Perfuração Esofágica/cirurgia , Humanos , Masculino , Mediastinite/complicações , Mediastinite/cirurgia , Pessoa de Meia-Idade , Pericardite/complicações , Pericardite/cirurgia
11.
J Electrocardiol ; 51(6): 1121-1123, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30497742

RESUMO

We herein describe a case of an acute pericarditis, in which type 1 Brugada phenocopy (BrP) was documented. The patient was referred to our hospital due to severe chest pain. The twelve-lead electrocardiogram (ECG) on admission showed type 1 Brugada ECG pattern (coved-type) in the precordial leads. Echocardiography only showed mild pericardial effusion. However, his ST segment elevation returned to normal and chest discomfort disappeared 3 weeks later. Our report addresses the possibility that the coved-type ST-segment elevation cannot be a sensitive finding for Brugada syndrome (BrS). Detailed tests are anyway needed to make appropriate diagnostic and therapeutic decisions.


Assuntos
Síndrome de Brugada/diagnóstico , Eletrocardiografia , Pericardite/diagnóstico , Doença Aguda , Síndrome de Brugada/diagnóstico por imagem , Dor no Peito/etiologia , Diagnóstico Diferencial , Ecocardiografia , Humanos , Masculino , Pericardite/complicações , Fenótipo , Sensibilidade e Especificidade , Adulto Jovem
12.
Kyobu Geka ; 71(12): 1023-1026, 2018 11.
Artigo em Japonês | MEDLINE | ID: mdl-30449871

RESUMO

A 69-year-old man was hospitalized urgently to the department of cardiology, with the progressive general malaise. On admission, his blood pressure was 80/42 mmHg, his white cell count 13,700/µl, and C-reactive protein 25.55 mg/dl suggesting existence of aggressive infection with impaired circulation. Massive pericardial effusion was detected in echocardiography. Pericardial drainage was undergone promptly. There was drainage of 700 ml and the property was purulent. Pneumococcus was detected by the culture test of the pericardial fluid. Antibiotic administration was started by a diagnosis of the purulent pericarditis. His general condition was improved. However, a rapidly expanding saccular aneurysm was found in a descending thoracic aorta by computed tomography( CT). As an infected thoracic aortic aneurysm secondary to the purulent pericarditis, we performed thoracic endovascular aneurysm repair (TEVAR). The intravenous administration of antibiotics was continued for 2 weeks after TEVAR, which was followed by oral antibiotic administration for 1 year. The aneurysm completely disappeared by CT, 10 months after TEVAR. In case with an infected thoracic aortic aneurysm, TEVAR can be a 1st choice of treatment, depending on a causative organism and the morphology of the aneurysm.


Assuntos
Aneurisma Infectado/etiologia , Aneurisma da Aorta Torácica/etiologia , Derrame Pericárdico/terapia , Pericardite/complicações , Idoso , Aneurisma Infectado/microbiologia , Aneurisma Infectado/terapia , Antibacterianos/uso terapêutico , Aorta Torácica , Aneurisma da Aorta Torácica/microbiologia , Aneurisma da Aorta Torácica/terapia , Proteína C-Reativa/análise , Drenagem/métodos , Humanos , Contagem de Leucócitos , Masculino , Derrame Pericárdico/diagnóstico por imagem , Derrame Pericárdico/microbiologia , Pericardite/microbiologia , Streptococcus pneumoniae/isolamento & purificação , Supuração/microbiologia , Supuração/terapia , Resultado do Tratamento
14.
BMJ Case Rep ; 20182018 Aug 03.
Artigo em Inglês | MEDLINE | ID: mdl-30076162

RESUMO

A 39-year-old man with known mitral regurgitation (MR) presented with chest pain, nausea and dizziness. Troponin of 5801 ng/L and scooped ST segments indicated myopericarditis. Cardiac MRI demonstrated an epicardial late gadolinium enhancement pattern consistent with a significantly myocarditic syndrome. Initially afebrile, the patient reported fevers a week earlier when abroad where he received amoxicillin.The patient then began spiking temperatures and infective endocarditis (IE) was confirmed following blood cultures positive for Streptococcus sanguinis and Transoesophageal echocardiography (TOE) showing a vegetation on the anterior mitral valve leaflet. Patient underwent 6 weeks of intravenous benzylpenicillin and on resolution he was discharged to await valve surgery.A model is proposed where septic embolism from IE caused bacterial myopericarditis, triggering the initial presenting complaint. It is suggested that prior antibiotic therapy and paracetamol suppressed the systemic symptoms of IE.


Assuntos
Endocardite Bacteriana/diagnóstico , Miocardite/complicações , Pericardite/complicações , Infecções Estreptocócicas/diagnóstico , Adulto , Antibacterianos/uso terapêutico , Ecocardiografia Transesofagiana , Eletrocardiografia , Embolia/etiologia , Endocardite Bacteriana/complicações , Endocardite Bacteriana/tratamento farmacológico , Humanos , Imagem Cinética por Ressonância Magnética , Masculino , Valva Mitral/diagnóstico por imagem , Valva Mitral/patologia , Penicilina G/uso terapêutico , Infecções Estreptocócicas/complicações , Infecções Estreptocócicas/tratamento farmacológico , Streptococcus sanguis/isolamento & purificação
15.
G Ital Cardiol (Rome) ; 19(9): 471-478, 2018 Sep.
Artigo em Italiano | MEDLINE | ID: mdl-30087507

RESUMO

Cardiac tamponade is a pericardial syndrome characterized by diastolic impairment due to the accumulation of pericardial fluid under pressure. It may be an acute life-threatening condition if not recognized and treated (e.g. cardiac tamponade by hemopericardium), or may present as a subacute condition allowing in some cases a delayed treatment.The causes of cardiac tamponade are the same as for pericardial effusion, primarily cancer in one third of cases (being lung cancer the most common type of cancer), bacterial infections (25% of cases), iatrogenic factors (15% of cases), and acute aortic disease with aortic dissection. Cardiac tamponade is reported in <1% of cases of myocardial infarction and is mainly due to heart rupture, or more rarely to hemorrhagic evolution of post-myocardial infarction pericarditis.Cardiac tamponade is a clinical diagnosis that is confirmed by echocardiography. The risk of recurrent cardiac tamponade is around 10% at 10-year follow-up and is mainly determined by the underlying etiology, with cancer patients showing the highest mortality.In this focused review, we will try to provide answers to the most common questions on the causes, presentation, diagnosis, treatment, and outcomes of cardiac tamponade.


Assuntos
Tamponamento Cardíaco/diagnóstico , Ecocardiografia/métodos , Derrame Pericárdico/diagnóstico , Doença Aguda , Tamponamento Cardíaco/etiologia , Tamponamento Cardíaco/terapia , Humanos , Infarto do Miocárdio/complicações , Neoplasias/complicações , Pericardite/complicações , Recidiva
17.
Lupus ; 27(11): 1769-1777, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30028258

RESUMO

Objectives This study aims to identify the factors associated with the development and mortality of pulmonary hypertension (PH) in systemic lupus erythematosus (SLE) patients. Methods We conducted a prospective study of SLE patients in a single tertiary center. PH was defined as a systolic pulmonary arterial pressure ≥30 mmHg on transthoracic echocardiography. We assessed potential associated factors contributing to the development and mortality of PH in SLE patients. Results Of 1110 patients with SLE, 48 patients were identified to have PH. Multivariable analysis indicated that pleuritis or pericarditis (odds ratio (OR) = 4.62), anti-RNP antibody (OR = 2.42), interstitial lung disease (ILD) (OR = 8.34) and cerebro-cardiovascular disease (OR = 13.37) were independently associated with the development of PH in SLE. Subgroup analysis among patients with PH demonstrated that there were no statistically significant factors associated with PH mortality in SLE. Conclusions The prevalence of PH was 4.3% in our cohort. There were significant associations with pleuritis or pericarditis, anti-RNP antibody, ILD, and cerebro-cardiovascular disease in SLE, which may contribute to the development of PH. However, there were no statistically significant factors associated with PH mortality in SLE.


Assuntos
Hipertensão Pulmonar/mortalidade , Hipertensão Pulmonar/fisiopatologia , Lúpus Eritematoso Sistêmico/complicações , Artéria Pulmonar/diagnóstico por imagem , Adulto , Pressão Sanguínea , Ecocardiografia Doppler em Cores , Feminino , Humanos , Modelos Logísticos , Doenças Pulmonares Intersticiais/complicações , Masculino , Análise Multivariada , Pericardite/complicações , Pleurisia/complicações , Estudos Prospectivos , República da Coreia/epidemiologia , Fatores de Risco , Análise de Sobrevida , Centros de Atenção Terciária , Adulto Jovem
19.
G Ital Cardiol (Rome) ; 19(7): 412-419, 2018.
Artigo em Italiano | MEDLINE | ID: mdl-29989598

RESUMO

Constrictive pericarditis is one of the most feared complications of patients with pericarditis, especially if recurrent. The common perception is that the higher the number of recurrences, the higher the risk of constriction. However, the risk of constriction is related to the etiology and not to the number of recurrences. Constriction has never been reported as a complication of idiopathic recurrent pericarditis, while the risk is low (<1%) after a first attack of idiopathic or viral pericarditis, intermediate for immune-mediated etiologies (2-5%, e.g. systemic inflammatory diseases, post-pericardiotomy syndromes) and cancer, and high especially for bacterial etiologies (20.30%, e.g. tuberculosis, purulent pericarditis). Constriction may be reversible in the setting of pericarditis and about 7-10% of patients with acute pericarditis may have transient constriction during the acute phase of inflammation, due to increased pericardial stiffness. Empiric anti-inflammatory therapy may prevent pericardiectomy in one half of cases.The clinical diagnosis is not easy but feasible with prompt recognition of the clinical symptoms and signs that may mimic heart failure and chronic hepatic disease (e.g. jugular vein distention, peripheral edema, ascites), the echocardiographic signs (e.g. septal bounce, respiratory variations of transmitral and tricuspid flows, annulus reversus, inferior vena cava plethora), and other imaging features (e.g. pericardial thickening in about 80% of cases, pericardial calcifications).In this paper, we will try to give an answer to common clinical doubts for assessing the risk of constriction, making the diagnosis, and addressing the therapy of these patients also underlying the possible outcomes.


Assuntos
Ecocardiografia/métodos , Pericardiectomia/métodos , Pericardite Constritiva/diagnóstico , Anti-Inflamatórios/administração & dosagem , Insuficiência Cardíaca/diagnóstico , Humanos , Hepatopatias/diagnóstico , Pericardite/complicações , Pericardite Constritiva/fisiopatologia , Pericardite Constritiva/terapia , Recidiva
20.
Clin Med (Lond) ; 18(3): 253-255, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29858438
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