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1.
Artigo em Japonês | MEDLINE | ID: mdl-33746175

RESUMO

OBJECTIVE: In cerebral angiography, the patient's exposure dose varies greatly depending on the target site, purpose, and difficulty of the procedure. Therefore, it is necessary to manage the dose based on not only the disease but also the procedure. METHODS: In this study, diagnostic cerebral angiography (diagnosis group) was classified into 13 procedures and neuro-interventional radiology (treatment group) was classified into 10 procedures, and the total dose, fluoroscopy dose, radiographic dose, fluoroscopy time, and number of radiographic frames were compared. RESULTS: For each item, the treatment group was significantly higher than the diagnosis group, but for some, the diagnosis group exceeded the median of treatment group. For the diagnosis group, the total irradiation time and fluoroscopy time were significant, and for the treatment group, all the items showed significant differences due to differences in procedures, and there were also cases where the same disease had differences due to procedures. CONCLUSION: To manage patient exposure in cerebral angiography, it is necessary to manage the usage rate and dose of fluoroscopy and radiography. In addition, it is important to evaluate, manage, and optimize the total dose, fluoroscopic dose, and radiographic dose for each procedure in not only the treatment group but also the diagnosis group.


Assuntos
Radiografia Intervencionista , Radiologia Intervencionista , Angiografia Cerebral , Fluoroscopia , Humanos , Doses de Radiação
3.
Radiol Clin North Am ; 59(2): 291-303, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33551088

RESUMO

Optimal assessment of the mediastinal masses is performed by a combination of clinical, radiological and often histological assessments. Image-guided transthoracic biopsy of mediastinal lesions is a minimally invasive and reliable procedure to obtain tissue samples, establish a diagnosis and provide a treatment plan. Biopsy can be performed under Computed Tomography, MRI, or ultrasound guidance, using a fine needle aspiration or a core-needle. In this paper, we review the image-guided strategies and techniques for histologic sampling of mediastinal lesions, along with the related clinical scenarios and possible procedural complications. In addition, image-guided mediastinal drainage and mediastinal ablations will be briefly discussed.


Assuntos
Técnicas de Ablação/métodos , Neoplasias do Mediastino/patologia , Neoplasias do Mediastino/cirurgia , Mediastino/diagnóstico por imagem , Radiografia Intervencionista/métodos , Radiologia Intervencionista/métodos , Humanos , Biópsia Guiada por Imagem , Imagem por Ressonância Magnética/métodos , Neoplasias do Mediastino/diagnóstico por imagem , Mediastino/patologia , Mediastino/cirurgia , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia de Intervenção/métodos
4.
Medicine (Baltimore) ; 100(6): e24732, 2021 Feb 12.
Artigo em Inglês | MEDLINE | ID: mdl-33578619

RESUMO

ABSTRACT: The aim of this study is to describe our clinical outcomes in isolated superior mesenteric artery dissection (SMAD) patients that underwent uncovered stent insertion.Between January 2016 and August 2019, consecutive isolated SMAD patients at our center were treated via uncovered stent insertion. Both short- and long-term outcomes in these patients were analyzed.Over the course of the study period, 11 total isolated SMAD patients meeting the criteria for stent insertion at our hospital were treated via uncovered stent insertion. Stent placement across the SMAD site was successful in all patients, with 1 stent being used per patient. There were no instances of procedure-related complications, and the median operative duration was 60 minutes. Patency of the distal superior mesenteric artery and branches thereof was achieved in all cases. Patients experienced progressive SMAD-related symptom relief and were followed for 6 to 49 months (median: 22 months). Over this follow-up period, the obliteration of the dissection was observed within 3 months in all patients. We did not detect any instances of stent occlusion, bowel ischemia, or anti-platelet-related bleeding during the follow-up period.Uncovered stent insertion can achieve favorable short- and long-term outcomes in isolated SMAD patients.


Assuntos
Aneurisma Dissecante/terapia , Artéria Mesentérica Superior , Idoso , Aneurisma Dissecante/diagnóstico por imagem , Angiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia Intervencionista , Estudos Retrospectivos , Stents
5.
Medicine (Baltimore) ; 100(5): e24333, 2021 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-33592879

RESUMO

ABSTRACT: To evaluate the clinical efficiency, feasibility, and safety of computed tomography (CT)-guided trans-scapular coil localization (TSCL) approach to treating scapula-blocked pulmonary nodules (SBPNs).In total, 105 patients with pulmonary nodules underwent CT-guided CL and subsequent video-assisted thoracoscopic surgery (VATS)-guided wedge resection (WR) between January 2016 and July 2020. Six of these patients (5.7%) had SBPNs that led them to undergo CT-guided TSCL. Rates of technical success and localization-related complications were then recorded and analyzed.CT-guided TSCL was associated with a 100% technical success rate, with one coil being placed per patient. The median CT-guided TSCL duration was 15 min. No patients experienced any complications associated with this procedure, and subsequent VATS-guided WR of SBPNs was 100% technically successful. In two patients with invasive adenocarcinoma, additional lobectomy was performed. Median VATS duration and intraoperative blood loss were 120 min and 150 mL, respectively.In summary, these results indicate that CT-guided TSCL could be easily and safely implemented to achieve high success rate when performing the VATS-guided WR of SBPNs.


Assuntos
Nódulos Pulmonares Múltiplos/cirurgia , Radiografia Intervencionista/métodos , Escápula/cirurgia , Cirurgia Torácica Vídeoassistida/métodos , Tomografia Computadorizada por Raios X/métodos , Idoso , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
6.
Medicine (Baltimore) ; 100(7): e24783, 2021 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-33607830

RESUMO

ABSTRACT: To evaluate the feasibility and potential value of 2D Parametric Parenchymal Blood Flow (2D-PPBF) for the assessment of perfusion changes following partial spleen embolization (PSE) in a retrospective observational study design.Overall, 12 PSE procedures in 12 patients were included in this study. The outcome of the study was the platelet response (PR), calculated as the percentage increase of platelet count (PLT), following PSE. To quantify perfusion changes using 2D-PPBF, the acquired digital subtraction angiography series were post-processed. A reference region-of-interest (ROI) was placed in the afferent splenic artery and a target ROI was positioned on the embolization territory of the spleen on digital subtraction angiography series pre- and post-embolization. The ratios of the target ROIs to the reference ROIs were calculated for the Wash-In-Rate (WIR), the Time-To-Peak (TTP) and the Area-Under-the-Curve (AUC). Comparisons between pre- and post-embolization data were made using Wilcoxon signed-rank test and Spearman's rank correlation coefficient (r). Afterwards, the study population was divided by the median of the TTP before PSE to analyze its value for the prediction of PR following PSE.Following PSE, PLT increased significantly from 43,000 ±â€Š21,405 platelets/µL to 128,500 ±â€Š66,083 platelets/µL with a PR of 255 ±â€Š243% (P = .003). In the embolized splenic territory, the pre-/post-embolization 2D-PPBF parameter changed significantly: WIRpre-PSE 1.23 ±â€Š2.42/WIRpost-PSE 0.09 ±â€Š0.07; -64 ±â€Š46% (p = 0.04), TTPpre-PSE 4.41 ±â€Š0.99/TTPpost-PSE 5.67 ±â€Š1.52 (P = .041); +34 ±â€Š47% and AUCpost-PSE 0.81 ±â€Š0.85/AUCpost-PSE 0.14 ±â€Š0.08; -71 ±â€Š18% (P = .002). A significant correlation of a 2D-PPBF parameter with the PLT was found for TTPpre-PSE/PLTpre-PSE r = -0.66 (P = .01). Subgroup analysis showed a significantly increased PR for the group with TTPpre-PSE >4.44 compared to the group with TTPpre-PSE ≤4.44 (404 ±â€Š267% versus 107 ±â€Š76%; P = .04).2D-PPBF is an objective approach to analyze the perfusion reduction of embolized splenic tissue. TTP derived from 2D-PPBF has the potential to predict the extent of PR during PSE.


Assuntos
Embolização Terapêutica/métodos , Hiperesplenismo/diagnóstico por imagem , Hipertensão Portal/diagnóstico por imagem , Artéria Esplênica/cirurgia , Adolescente , Adulto , Angiografia Digital/métodos , Embolização Terapêutica/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Hiperesplenismo/etiologia , Hiperesplenismo/cirurgia , Hipertensão Portal/complicações , Hipertensão Portal/cirurgia , Masculino , Pessoa de Meia-Idade , Radiografia Intervencionista , Adulto Jovem
7.
Br J Radiol ; 94(1120): 20200754, 2021 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-33544633

RESUMO

OBJECTIVE: We investigated the efficacy and exposure to radiation in 320-detector row computed tomography fluoroscopy-guided (CTF-guided) interventions. METHODS: We analysed 231 320-detector row CTF-guided interventions (207 patients over 2 years and 6 months) in terms of technical success rates, clinical success rates, complications, scanner settings, overall radiation doses (dose-length product, mGy*cm), patient doses of peri-interventional CT series, and interventional CT (including CTF), as a retrospective cohort study. The relationships between patient radiation dose and interventional factors were assessed using multivariate analysis. RESULTS: Overall technical success rate was 98.7% (228/231). The technical success rates of biopsies, drainages, and aspirations were 98.7% (154/156), 98.5% (66/67), and 100% (8/8), respectively. The clinical success rate of biopsies was 93.5% (146/156). All three major complications occurred in chest biopsies. The median total radiation dose was 522.4 (393.4-819.8) mGy*cm. Of the total radiation dose, 87% was applied during the pre- and post-interventional CT series. Post-interventional CT accounted for 24.4% of the total radiation dose. Only 11.4% of the dose was applied by CTF-guided intervention. Multilinear regression demonstrated that male sex, body mass index, drainage, intervention time, and helical scan as post-interventional CT were significantly associated with higher dose. CONCLUSION: The 320-detector row CTF interventions achieved a high success rate. Dose reduction in post-interventional CT provides patient dose reduction without decreasing the technical success rates. ADVANCES IN KNOWLEDGE: This is the first study on the relationship between various interventional outcomes and patient exposure to radiation in 320-detector row CTF-guided interventions, suggesting a new perspective on dose reduction.


Assuntos
Exposição à Radiação/estatística & dados numéricos , Radiografia Intervencionista/métodos , Tomografia Computadorizada por Raios X/métodos , Idoso , Estudos de Coortes , Feminino , Fluoroscopia , Humanos , Masculino , Estudos Retrospectivos , Resultado do Tratamento
8.
Br J Radiol ; 94(1120): 20201234, 2021 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-33565896

RESUMO

OBJECTIVE: To determine the sensitivity, specificity and accuracy of CT-guided needle biopsy (CT-NB) for distinguishing benign and malignant lesions in children with suspected primary bone tumours, and to assess the correlation between imaging diagnosis and final diagnosis. METHODS: Retrospective review of children who underwent CT-NB of a suspected primary bone tumour between October 2016 and October 2019. Data collected included anatomical location, imaging diagnosis, type of needle, type of biopsy sample, CT-NB diagnosis, final diagnosis and post-procedural complications. The final diagnosis was established based on surgical histology or clinical/imaging follow-up. RESULTS: 125 patients met the inclusion criteria (68M, 57F: mean age 11 years; range 10 months-18 years). Biopsy was performed using a 10 cm Jamshidi needle (10G n = 96; 13 G n = 8); 14G Tru-Cut needle (n = 18); 14G Temno needle (n = 3). The commonest anatomical locations were the femur (n = 40), tibia (n = 25) and humerus (n = 16), while the commonest diagnoses were osteosarcoma (n = 35), CRMO (n = 15) and LCH (n = 14). A benign tumour was correctly identified on imaging in 100% of cases, and a malignant tumour in 95.8%. Sensitivity, specificity and diagnostic accuracy of CT-NB for distinguishing malignant from benign lesions were 98%, 100 and 99%. Of 24 indeterminate biopsy results, all that had a non-aggressive radiological appearance were benign. No immediate complications were recorded. CONCLUSION: CT-NB represents a safe and very effective tool for differentiating benign and malignant lesions in children presenting with a suspected primary bone tumour. Suspected radiological diagnosis plays a pivotal role in the management of indeterminate biopsy results. ADVANCES IN KNOWLEDGE: Paediatric bone tumours pose a significant diagnostic and therapeutic challenge. The interpretation of the imaging findings is essential for the successful management of indeterminate histological results.


Assuntos
Neoplasias Ósseas/diagnóstico por imagem , Neoplasias Ósseas/patologia , Radiografia Intervencionista/métodos , Tomografia Computadorizada por Raios X/métodos , Adolescente , Osso e Ossos/diagnóstico por imagem , Osso e Ossos/patologia , Criança , Pré-Escolar , Diagnóstico Diferencial , Feminino , Humanos , Biópsia Guiada por Imagem , Lactente , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade
9.
Radiologe ; 61(2): 159-165, 2021 Feb.
Artigo em Alemão | MEDLINE | ID: mdl-33427890

RESUMO

BACKGROUND: Interventional methods of the breast serve as percutaneous minimally invasive diagnostic tools in case of suspicious findings in the breast or axilla. Further indications are lesion localization and the minimally invasive therapeutic approach. OBJECTIVES: Aim of this paper is to give an overview of the existing methods, their indications and the imaging techniques for guidance. On the basis of the most recent publications, clinical management is described.


Assuntos
Neoplasias da Mama , Radiografia Intervencionista , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/cirurgia , Feminino , Humanos
14.
J Vasc Interv Radiol ; 32(2): 220-225.e2, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33461874

RESUMO

PURPOSE: To evaluate the impact of a versatile flexible ceiling-mounted C-arm on active table and gantry repositioning during interventions and its effect on operator discomfort, system usability, and patient safety compared with a traditional ceiling-mounted system. MATERIALS AND METHODS: There were 100 IR procedures studied: 50 in a traditional IR system (standard group) and 50 with a novel multiaxis ceiling-mounted system (test group). FlexArm was capable of multiple gantry rotation points allowing increased access to the patient in addition to 236 cm of lateral x-ray detector travel. For each procedure, both the table and the gantry repositioning were measured. Patient safety, patient/equipment repositioning effort, and physical discomfort were evaluated through an operator survey. RESULTS: Table repositioning was reduced from 42 to 16 instances per procedure (P < .001) in the test group compared with the standard group. The operators perceived less table and gantry repositioning effort (P < .0001) and decreased risks of equipment collisions, displacement of vascular access, and dislodgment of tubes/lines with the test group (P < .0001). Operator discomfort was reduced for all body areas in the test group over the standard group (P < .0001). CONCLUSIONS: The FlexArm system geometry enhances operator ergonomics, as there was a decrease need to move the table, leading to a perceived decrease in patient risk and decrease operator physical discomfort when compared to a traditional imaging system.


Assuntos
Angiografia/instrumentação , Ergonomia , Radiografia Intervencionista/instrumentação , Radiologistas , Angiografia/efeitos adversos , Desenho de Equipamento , Humanos , Doenças Musculoesqueléticas/etiologia , Doenças Musculoesqueléticas/prevenção & controle , Doenças Profissionais/etiologia , Doenças Profissionais/prevenção & controle , Saúde do Trabalhador , Posicionamento do Paciente , Segurança do Paciente , Estudos Prospectivos , Radiografia Intervencionista/efeitos adversos , Fluxo de Trabalho
17.
Br J Radiol ; 94(1117): 20190878, 2021 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-33090887

RESUMO

OBJECTIVE: Mini C-arm fluoroscopes are widely used by orthopaedic surgeons for intraoperative image guidance without the need for radiographers. This puts the responsibility for radiation exposure firmly with the operating surgeon. In order to maintain safe and best practice under U.K. Ionising Radiation (Medical Exposure) Regulations, one must limit radiation exposure and audit performance using national diagnostic reference levels (DRLs). In the case of the mini C-arm, there are no national DRLs. IR(ME)R, therefore, require the establishment of local DRLs by each hospital to act as an alternative guideline for safe radiation use. The aim of our audit was to establish local DRLs based on our experience operating with the use of the mini C-arm over the last 7 years. METHODS: This retrospective audit evaluates the end dose-area product (DAP) recorded for common trauma and orthopaedic procedures using the mini C-arm in a busy district general hospital.We present the quartile data and have set the cut-off point as the third quartile for formulating the local DRLs, consistent with the methodology for the conventional fluoroscope. RESULTS: For our data set (n = 1664), the third quartile DAP values were lowest for surgeries to the forearm (5.38 cGycm2), hand (7.62 cGycm2), and foot/ankle (8.56 cGycm2), and highest for wrist (10.64 cGycm2) and elbow (14.61 cGycm2) procedures. ADVANCES IN KNOWLEDGE: To our knowledge, this is the largest data set used to establish local DRLs. Other centres may find our guidelines useful whilst they establish their own local DRLs.


Assuntos
Procedimentos Ortopédicos , Doses de Radiação , Exposição à Radiação/estatística & dados numéricos , Radiografia Intervencionista/instrumentação , Radiografia Intervencionista/métodos , Fluoroscopia/instrumentação , Fluoroscopia/métodos , Humanos , Cuidados Intraoperatórios/métodos , Valores de Referência , Estudos Retrospectivos , Reino Unido
18.
Br J Radiol ; 94(1117): 20200633, 2021 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-33125260

RESUMO

OBJECTIVE: To develop and validate a CT-based nomogram to predict the occurrence of loculated pneumothorax due to hook wire placement. METHODS: Patients (n = 177) were divided into pneumothorax (n = 72) and non-pneumothorax (n = 105) groups. Multivariable logistic regression analysis was applied to build a clinical prediction model using significant predictors identified by univariate analysis of imaging features and clinical factors. Receiver operating characteristic (ROC) was applied to evaluate the discrimination of the nomogram, which was calibrated using calibration curve. RESULTS: Based on the results of multivariable regression analysis, transfissure approach [odds ratio (OR): 757.94; 95% confidence interval CI (21.20-27099.30) p < 0.0001], transemphysema [OR: 116.73; 95% CI (12.34-1104.04) p < 0.0001], localization of multiple nodules [OR: 8.04; 95% CI (2.09-30.89) p = 0.002], and depth of nodule [OR: 0.77; 95% CI (0.71-0.85) p < 0.0001] were independent risk factors for pneumothorax and were included in the predictive model (p < 0.05). The area under the ROC curve value for the nomogram was 0.95 [95% CI (0.92-0.98)] and the calibration curve indicated good consistency between risk predicted using the model and actual risk. CONCLUSION: A CT-based nomogram combining imaging features and clinical factors can predict the probability of pneumothorax before localization of ground-glass nodules. The nomogram is a decision-making tool to prevent pneumothorax and determine whether to proceed with further treatment. ADVANCES IN KNOWLEDGE: A nomogram composed of transfissure, transemphysema, multiple nodule localization, and depth of nodule has been developed to predict the probability of pneumothorax before localization of GGNs.


Assuntos
Neoplasias Pulmonares/diagnóstico por imagem , Pneumotórax/diagnóstico por imagem , Cuidados Pré-Operatórios/métodos , Nódulo Pulmonar Solitário/diagnóstico por imagem , Cirurgia Torácica Vídeoassistida/instrumentação , Tomografia Computadorizada por Raios X/métodos , Feminino , Humanos , Pulmão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Nomogramas , Pneumotórax/etiologia , Valor Preditivo dos Testes , Cuidados Pré-Operatórios/instrumentação , Radiografia Intervencionista , Reprodutibilidade dos Testes , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/métodos
19.
Br J Radiol ; 94(1117): 20200774, 2021 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-33180554

RESUMO

OBJECTIVES: In fluoroscopy-guided interventional practices, new dose reduction systems have proved to be efficient in the reduction of patient doses. However, it is not clear whether this reduction in patient dose is proportionally transferred to operators' doses. This work investigates the secondary radiation fields produced by two kinds of interventional cardiology units from the same manufacturer with and without dose reduction systems.Methods:Data collected from a large sample of clinical procedures over a 2-year period (more than 5000 procedures and 340,000 radiation events) and the DICOM radiation dose structured reports were analysed. RESULTS: The average cumulative Hp(10) per procedure measured at the C-arm was similar for the standard and the dose reduction systems (452 vs 476 µSv respectively). The events analysis showed that the ratio Hp(10)/KAP at the C-arm was (mean ± SD) 5 ± 2, 10 ± 4, 14 ± 4 and 14 ± 6 µSv·Gy-1·cm-2 for the beams with no added filtration, 0.1, 0.4 and 0.9 mm Cu respectively and suggested that the main cause for the increment of the ratio Hp(10)/KAP vs the "standard system" is the use of higher beam filtration in the "dose reduction" system. CONCLUSION: Dose reduction systems are beneficial to reduce KAP in patients and their use should be encouraged, but they may not be equally effective to reduce occupational doses. Interventionalists should not overlook their own personal protection when using new technologies with dose reduction systems. ADVANCES IN KNOWLEDGE: Dose reduction technology in interventional systems may increase scatter dose for operators. Personal protection should not be overlooked with dose reduction systems.


Assuntos
Exposição Ocupacional/estatística & dados numéricos , Doses de Radiação , Monitoramento de Radiação/estatística & dados numéricos , Proteção Radiológica/métodos , Radiografia Intervencionista/estatística & dados numéricos , Fluoroscopia , Humanos , Monitoramento de Radiação/métodos
20.
J Vasc Interv Radiol ; 32(2): 226-234, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33339678

RESUMO

PURPOSE: To prospectively validate electromagnetic hand motion tracking in interventional radiology to detect differences in operator experience using simulation. METHODS: Sheath task: Six attending interventional radiologists (experts) and 6 radiology trainees (trainees) placed a wire through a sheath and performed a "pin-pull" maneuver, while an electromagnetic motion detection system recorded the hand motion. Radial task: Eight experts and 12 trainees performed palpatory radial artery access task on a radial access simulator. The trainees repeated the task with the nondominant hand. The experts were classified by their most frequent radial artery access technique as having either palpatory, ultrasound, or overall limited experience. The time, path length, and number of movements were calculated. Mann-Whitney U tests were used to compare the groups, and P < .05 was considered significant. RESULTS: Sheath task: The experts took less time, had shorter path lengths, and used fewer movements than the trainees (11.7 seconds ± 3.3 vs 19.7 seconds ± 6.5, P < .01; 1.1 m ± 0.3 vs 1.4 m ± 0.4, P < .01; and 19.5 movements ± 8.5 vs 31.0 movements ± 8.0, P < .01, respectively). Radial task: The experts took less time, had shorter path lengths, and used fewer movements than the trainees (24.2 seconds ± 10.6 vs 33.1 seconds ± 16.9, P < .01; 2.0 m ± 0.5 vs 3.0 m ± 1.9, P < .001; and 36.5 movements ± 15.0 vs 54.5 movements ± 28.0, P < .001, respectively). The trainees had a shorter path length for their dominant hand than their nondominant hand (3.0 m ± 1.9 vs 3.5 m ± 1.9, P < .05). The expert palpatory group had a shorter path length than the ultrasound and limited experience groups (1.8 m ± 0.4 vs 2.0 m ± 0.4 and 2.3 m ± 1.2, respectively, P < .05). CONCLUSIONS: Electromagnetic hand motion tracking can differentiate between the expert and trainee operators for simulated interventional tasks.


Assuntos
Cateterismo Periférico , Competência Clínica , Fenômenos Eletromagnéticos , Mãos , Destreza Motora , Artéria Radial , Radiografia Intervencionista , Radiologistas , Fenômenos Biomecânicos , Estudos de Viabilidade , Humanos , Projetos Piloto , Estudos Prospectivos , Punções , Fatores de Tempo
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