scholarly journals Lyme Carditis in an Immunocompromised Patient

2013 ◽  
Vol 2013 ◽  
pp. 1-3 ◽  
Author(s):  
Matthew F. Ryan ◽  
Coben Thorn
Keyword(s):  
Heart Block ◽  
Solid Organ ◽  
Lyme Carditis ◽  
Number Of Patients ◽  
Chief Complaints ◽  
Immunosuppressed Patients ◽  
History Of ◽  
Treatment Plans ◽  
Vector Borne ◽  
Special Patient Population

We present a case of a 68-year-old man with a history of liver transplant and of chronic immunosuppression therapy who presented to the emergency department (ED) for fevers and worsening fatigue for two days. On further investigation, the patient was found to have a new first-degree heart block on his electrocardiograph. Coupled with the history of a recent tick bite, the patient was diagnosed with vector-borne carditis. Although the patient’s titers for various vectors remained negative, due to a long history of immunosuppression, he was treated for Lyme disease and his heart block completely resolved with antibiotic treatment. We describe details of the case as well as discuss the impacts of immunosuppression on vector-borne disease. Immunosuppressed patients represent a special population and can present with chief complaints made even more complicated by their medical history, and this case illustrates the importance of being mindful of how immunosuppression can affect a patient’s presentation. As the efficacy of antirejection medications improved, the ED may see an increasing number of patients with solid organ transplants. A greater understanding of this special patient population is key to formulating optimal treatment plans.

scholarly journals Cancer immunotherapy in special challenging populations: recommendations of the Advisory Committee of Spanish Melanoma Group (GEM)

2021 ◽  
Vol 9 (3) ◽  
pp. e001664
Author(s):  
Maria Gonzalez-Cao ◽  
Teresa Puertolas ◽  
Mar Riveiro ◽  
Eva Muñoz-Couselo ◽  
Carolina Ortiz ◽  
...  
Keyword(s):  
Cancer Immunotherapy ◽  
Multidisciplinary Approach ◽  
Checkpoint Inhibitors ◽  
Solid Organ Transplantation ◽  
Latent Tuberculosis ◽  
Solid Organ ◽  
Chronic Infections ◽  
Immunosuppressed Patients ◽  
History Of ◽  
Evidence Based Guidelines

Cancer immunotherapy based on the use of antibodies targeting the so-called checkpoint inhibitors, such as programmed cell death-1 receptor, its ligand, or CTLA-4, has shown durable clinical benefit and survival improvement in melanoma and other tumors. However, there are some special situations that could be a challenge for clinical management. Persons with chronic infections, such as HIV-1 or viral hepatitis, latent tuberculosis, or a history of solid organ transplantation, could be candidates for cancer immunotherapy, but their management requires a multidisciplinary approach. The Spanish Melanoma Group (GEM) panel in collaboration with experts in virology and immunology from different centers in Spain reviewed the literature and developed evidence-based guidelines for cancer immunotherapy management in patients with chronic infections and immunosuppression. These are the first clinical guidelines for cancer immunotherapy treatment in special challenging populations. Cancer immunotherapy in chronically infected or immunosuppressed patients is feasible but needs a multidisciplinary approach in order to decrease the risk of complications related to the coexistent comorbidities.

scholarly journals The Importance of Screening Strongyloides stercoralis Infection in Solid Organ Transplant Donors and Recipients

2021 ◽  
Vol 16 (4) ◽  
Author(s):  
Sara Abolghasemi ◽  
Farnaz Zolfaghari ◽  
Shahnaz Sali ◽  
Abdollah Ghaffari ◽  
Mehran Noori
Keyword(s):  
Organ Transplant ◽  
Gastrointestinal Symptoms ◽  
Strongyloides Stercoralis ◽  
Solid Organ Transplant ◽  
Solid Organ ◽  
Kidney Transplant Recipients ◽  
Place Of Residence ◽  
Birth Place ◽  
Immunosuppressed Patients ◽  
History Of

Background: Strongyloides stercoralis is an intestinal nematode with worldwide distribution which is endemic in tropical and subtropical areas. It is unique in its ability to complete its entire life cycle and reinfect its human host via a phenomenon called autoinfection. The majority of infections are clinically asymptomatic or can manifest with gastrointestinal symptoms, such as heartburn, bloating, diarrhea, abdominal discomfort, gastroesophageal reflux disease (GERD), or symptoms related to the penetration of larvae through skin, including dermatitis and eosinophilia. Immunosuppressed patients, such as solid organ transplant patients with untreated strongyloidiasis are at great risk of hyperinfection, dissemination syndromes, and often fatal conditions associated with strongyloidiasis. Methods: In this retrospective single-center cross-sectional study, we evaluated 157 cases (131 heart, lung, and kidney transplant recipients and 26 kidney donors) in Tehran, Iran, from March 2020 to April 2021. Demographic information including age, gender, place of birth, place of residence, underlying disease, being the donor or recipient, history of previous transplant and type of transplant, travel history to endemic regions, and seropositivity for S. stercoralis were evaluated. Results: Among 157 cases with a mean age of 38.9 years, 40 (25.5%) cases tested positive for S. stercoralis antibodies. Out of 26 donors, eight cases were seropositive, and among 131 recipients, 32 cases were seropositive. There was no significant correlation between birth place and place of residence in endemic areas and seropositivity for S. stercoralis. None of the cases showed hypereosinophilia, hyperinfection, or disseminated syndrome. Also, we found no significant correlation between the type and time of transplant, history of previous transplants, and S. stercoralis infection. Conclusions: Universal screening for S. stercoralis latent infection is important in immunosuppressed patients, especially in solid organ transplants because of the high risk of hyperinfection and disseminated syndrome, which may culminate in death. Furthermore, screening for latent strongyloides infection in donors seems to be necessary because of the possibility of strongyloides infection being transmitted from donors to recipients.

scholarly journals COVID-19—Importance for Patients on the Waiting List and after Kidney Transplantation—A Single Center Evaluation in 2020–2021

Pathogens ◽  
2021 ◽  
Vol 10 (4) ◽  
pp. 429
Author(s):  
Simone C. Boedecker ◽  
Pascal Klimpke ◽  
Daniel Kraus ◽  
Stefan Runkel ◽  
Peter R. Galle ◽  
...  
Keyword(s):  
Kidney Transplantation ◽  
Waiting List ◽  
Smoking History ◽  
Immunocompromised Patients ◽  
Dialysis Patients ◽  
Vaccination Programs ◽  
Mild Disease ◽  
Probability Of Survival ◽  
Number Of Patients ◽  
Immunosuppressed Patients

(1) Background: Dialysis patients and recipients of a kidney allograft are at high risk for infection with SARS-CoV-2. It has been shown that the development of potent neutralizing humoral immunity against SARS CoV-2 leads to an increased probability of survival. However, the question of whether immunocompromised patients develop antibodies has not yet been sufficiently investigated; (2) Methods: SARS-CoV-2 antibodies were examined in hemodialysis patients on the waiting list for kidney transplantation as well as patients after kidney transplantation. Patients were interviewed about symptoms and comorbidities, BMI, and smoking history; (3) Results: SARS-CoV-2 antibodies were found in 16 out of 259 patients (6%). The trend of infections here reflects the general course of infection in Germany with a peak in November/December of 2020. Remarkably, patients on the waiting list experienced only mild disease. In contrast, transplanted patients had to be hospitalized but recovered rapidly from COVID-19. Most interesting is that all immunosuppressed patients developed antibodies against SARS-CoV-2 after infection; (4) Conclusions: Even with extensive hygiene concepts, an above-average number of patients were infected with SARS-CoV-2 during the second wave of infections in Germany. Because SARS-CoV-2 infection triggered the formation of antibodies even in these immunocompromised patients, we expect vaccination to be effective in this group of patients. Thus, dialysis patients and patients after kidney transplantation should be given high priority in vaccination programs.

scholarly journals 570. “I don’t know”: The Typical Response When Taking Pneumococcal Immunization Histories in Kidney Transplant Candidates

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S349-S351
Author(s):  
Jahanavi M Ramakrishna ◽  
Tambi Jarmi ◽  
Claudia R Libertin
Keyword(s):  
Infectious Disease ◽  
Kidney Transplant ◽  
Pneumococcal Vaccine ◽  
Patient Population ◽  
Pneumococcal Vaccination ◽  
Prior History ◽  
Vaccine Preventable Diseases ◽  
Number Of Patients ◽  
Order Completion ◽  
History Of

Abstract Background Vaccine-preventable diseases account for significant morbidity and mortality in the kidney transplant (KT) patient population. AST Guidelines support review and documentation of pneumococcal vaccines in KT candidate infectious disease (ID) evaluations. The objective of this study is to determine the number of KT candidates screened for prior pneumococcal immunizations and the frequency of vaccines ordered by providers when indicated at Mayo Clinic Florida’s (MCF) Transplant Center. Methods This study was an institution-based retrospective analysis of all KT candidates evaluated at MCF from December 2, 2019 – January 14, 2020. Data collection was obtained by electronic health record review. Outcomes included known history and documentation rates of prior pneumococcal vaccinations (both Prevnar 13 and Pneumovax 23) by infectious disease (ID) providers, as well as pneumococcal vaccine order frequency during ID pre-transplant evaluation when indicated. Data analysis was done using simple descriptive statistics. Results Sixty-one patients underwent KT evaluation during the study period. Among the 61 patients, 20 (32.8%) and 20 (32.8%) had a known prior history of receiving Prevnar 13 and Pneumovax 23 vaccinations, respectively. Vaccine history was unknown for Prevnar 13 and Pneumovax 23 in 39 (63.9%) patients. Vaccine status was not documented by ID providers in 2 (3.3%) patients. When appropriate, ID providers ordered Prevnar 13 and Pneumovax 23 in 38 (92.7%) and 41 (100%) patients, respectively. Orders included both electronic and written documentation to account for patients planning immunization elsewhere. Of the 38 patients advised to receive the Prevnar 13 vaccine, 17 (41.5%) patients were documented completing immunization. Pneumovax 23 order completion rates were not recorded since the study period only lasted six weeks due to closure by COVID-19. Table 1. Pneumococcal Vaccine History Documentation Rates Obtained by Patient Recall or Records Table 2. Pneumococcal Vaccine Order Rates at Pre-Kidney Transplant Consultations Table 3. Prevnar 13 Order Completion Rate by Documentation Conclusion The data reflect a high number of patients who either do not recall or have documentation of prior pneumococcal vaccination available at time of KT ID evaluation. Providers documented history of pneumococcal vaccinations extremely well, ordering immunizations when necessary. This study highlights lack of portability of immunization histories in a given patient population and opportunity for improved care. Disclosures Claudia R. Libertin, MD, Pfizer, Inc. (Grant/Research Support, Research Grant or Support)

scholarly journals Hemi- and Homozygous Loss-of-Function Mutations in DSG2 (Desmoglein-2) Cause Recessive Arrhythmogenic Cardiomyopathy with an Early Onset

2021 ◽  
Vol 22 (7) ◽  
pp. 3786
Author(s):  
Andreas Brodehl ◽  
Alexey Meshkov ◽  
Roman Myasnikov ◽  
Anna Kiseleva ◽  
Olga Kulikova ◽  
...  
Keyword(s):  
Medical History ◽  
Splice Site Mutation ◽  
Pathogenic Mutation ◽  
Large Deletion ◽  
Loss Of Function ◽  
Arrhythmogenic Cardiomyopathy ◽  
Site Mutation ◽  
Snp Arrays ◽  
Number Of Patients ◽  
History Of

About 50% of patients with arrhythmogenic cardiomyopathy (ACM) carry a pathogenic or likely pathogenic mutation in the desmosomal genes. However, there is a significant number of patients without positive familial anamnesis. Therefore, the molecular reasons for ACM in these patients are frequently unknown and a genetic contribution might be underestimated. Here, we used a next-generation sequencing (NGS) approach and in addition single nucleotide polymor-phism (SNP) arrays for the genetic analysis of two independent index patients without familial medical history. Of note, this genetic strategy revealed a homozygous splice site mutation (DSG2–c.378+1G>T) in the first patient and a nonsense mutation (DSG2–p.L772X) in combination with a large deletion in DSG2 in the second one. In conclusion, a recessive inheritance pattern is likely for both cases, which might contribute to the hidden medical history in both families. This is the first report about these novel loss-of-function mutations in DSG2 that have not been previously identi-fied. Therefore, we suggest performing deep genetic analyses using NGS in combination with SNP arrays also for ACM index patients without obvious familial medical history. In the future, this finding might has relevance for the genetic counseling of similar cases.

scholarly journals Reactivation of BK Polyomavirus in Urine Cytology Is Not Associated with Urothelial Cell Carcinoma

Viruses ◽  
2020 ◽  
Vol 12 (12) ◽  
pp. 1412
Author(s):  
Faisal Klufah ◽  
Ghalib Mobaraki ◽  
Axel zur Hausen ◽  
Iryna V. Samarska
Keyword(s):  
Cell Carcinoma ◽  
Urine Cytology ◽  
Urothelial Cell ◽  
The Other ◽  
Urothelial Cell Carcinoma ◽  
Tissue Samples ◽  
Bk Polyomavirus ◽  
Ffpe Tissues ◽  
Immunosuppressed Patients ◽  
History Of

BK polyomavirus (BKPyV) has been associated with some high-grade and special urothelial cell carcinoma (UCC) subtypes in immunosuppressed patients. Here, we evaluated the relationship of BKPyV-positive urine cytology specimens (UCS) with UCC. A large single-institution database was retrospectively searched for UCS positive for decoy cells, suggesting BKPyV infection. These were tested for the presence of BKPyV by PCR and immunohistochemistry (IHC) in urine sediments and formalin-fixed paraffin-embedded (FFPE) tissue samples of UCC. Decoy cells were reported in 30 patients out of the database with 22.867 UCS. Of these 30 patients, 16 (53.3%) had no history of UCC. Six patients out of these 16 had a history of transplantation, 4 had a history of severe chronic medical conditions, and 6 had no chronic disease. The other fourteen patients were diagnosed with either in situ or invasive UCC of the urinary bladder (14/30; 46.6%) prior to the detection of decoy cells in the urine. Nine of these UCC patients received intravesical treatment (BCG or mitomycin) after the first presentation with UCC. However, the clinical data on the treatment of the other five UCC patients was lacking. IHC identified BKPyV-positivity in the urine samples of non-UCC and UCC patients, while no BKPyV positivity was found in FFPE tissues of primary UCCs and metastases. In addition, BKPyV-PCR results revealed the presence of BKPyV DNA in the urine of the UCC cases, yet none in the UCC tissues itself. These data strongly indicate that BKPyV reactivation is not restricted to immunosuppression. It can be found in UCS of the immunocompetent patients and may be related to the intravesical BCG or mitomycin treatment of the UCC patients.

A Useful Diagnostic Method for Drug-induced Pneumonitis

1994 ◽  
Vol 22 (03n04) ◽  
pp. 329-336 ◽  
Author(s):  
Akira Kawasaki ◽  
Yutaka Mizushima ◽  
Hitoshi Kunitani ◽  
Masanobu Kitagawa ◽  
Masashi Kobayashi
Keyword(s):  
Bronchoalveolar Lavage Fluid ◽  
Challenge Test ◽  
Lavage Fluid ◽  
Peripheral Blood Lymphocytes ◽  
Lymphocyte Stimulation Test ◽  
Drug Induced ◽  
Chief Complaints ◽  
History Of ◽  
Chest X Ray

A 51 year-old male was admitted to our hospital with chief complaints of fever, dry cough and dyspnea. Chest X -ray films and his history of taking Chinese medicine for liver dysfunction were suggestive of drug-induced pneumonitis. Lymphocyte stimulation test (LST) to causative Chinese medical drugs of Sho-saiko-to and Dai-saiko-to was negative with peripheral blood lymphocytes (PBL), but was positive with Iymphocytes from bronchoalveolar lavage fluid (BALF). In vivo challenge test for Sho-saiko-to was positive. The LST with BALF-lymphocytes proved to be very useful in making a diagnosis of drug-induced pneumonitis.

scholarly journals Occupational Exposure to Varicella Zoster in a Tertiary-Care Healthcare Setting

2020 ◽  
Vol 41 (S1) ◽  
pp. s333-s334
Author(s):  
Zachary Yetmar ◽  
Debra Apenhorst ◽  
Priya Sampathkumar ◽  
Elena Beam
Keyword(s):  
Occupational Exposure ◽  
Varicella Zoster Virus ◽  
Tertiary Care ◽  
Occupational Exposures ◽  
Inpatient Setting ◽  
Solid Organ ◽  
Immunocompromised Patients ◽  
Varicella Zoster ◽  
Delayed Initiation ◽  
Immunosuppressed Patients

Background: Disseminated varicella zoster virus (dVZV) infection is a feared complication of varicella zoster virus (VZV) reactivation in immunocompromised patients. The CDC recommends contact and airborne precautions for localized VZV in immunocompromised patients until dissemination has been ruled out. Pre-emptive isolation can be problematic for medical centers without access to negative-pressure rooms. When we identify a case of dVZV at our facility, we perform an investigation to identify occupational exposures. Methods: We conducted a retrospective, descriptive review of occupational exposure investigations related to dVZV from January 2016 to December 2018. We collected baseline characteristics of the dVZV patient, and we evaluated whether the exposure occurred due to a delay in diagnosis or a progression from “localized” to disseminated VZV disease. Results: We identified 21 immunosuppressed patients with dVZV whose infection resulted in an occupational exposure during the specified study period. Average age was 58.6 years, with 10 males and 12 females. The immunocompromised patients included 11 with hematologic malignancy, 5 with solid-organ malignancy, 3 with rheumatologic disease on immunosuppressive therapy, and 2 with a solid-organ transplant. Most of the exposures (72.7%) occurred in an inpatient setting. The exposures resulted from either delayed recognition of dVZV or delayed initiation of appropriate precautions for all of the immunosuppressed patients. Two additional exposures occurred as a result of a change from “localized” to “disseminated” VZV. These patients whose diagnosis changed from localized to dVZV were considered previously immunocompetent, and dissemination took place 2 days after seeking healthcare evaluation. Conclusions: Most occupational exposures to varicella zoster are the result of delayed initiation of appropriate isolation precautions due to delayed diagnosis of dVZV infection or failure to recognize the need for instituting precautions in disseminated disease. Instituting preemptive airborne precautions for immunocompromised patients with localized varicella zoster would be unlikely to reduce occupational exposures.Funding: NoneDisclosures: Consulting fee- Merck Priya Sampathkumar

Abstract TMP8: The New Alteplase Package Insert: What is the Potential Impact?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Harn Shiue ◽  
Karen Albright ◽  
Kara Sands ◽  
April Sisson ◽  
Michael Lyerly ◽  
...  
Keyword(s):  
Health Care ◽  
Ischemic Stroke ◽  
Health Care Costs ◽  
Lifetime Cost ◽  
Package Insert ◽  
Cost Savings ◽  
Number Of Patients ◽  
History Of ◽  
Potential Impact ◽  
Care Costs

Background: Alteplase (tPA) contraindications for acute ischemic stroke (AIS) were originally derived from the 1995 NINDS trial. Recently, a history of intracranial hemorrhage (ICH) and recent stroke (within 3 months) were removed as contraindications from the drug package insert, which could increase the number of patients eligible for IV thrombolysis. We sought to define the potential impact on outcomes and health care costs in this newly eligible population. Methods: Consecutive patients (March 2014 - April 2015) who presented with AIS to our Comprehensive Stroke Center (CSC) were retrospectively analyzed. Demographics and tPA exclusions were recorded. The annual number of discharges with primary diagnosis of ischemic stroke in the U.S. was estimated from the National Inpatient Sample (2006 - 2011). A previously reported value of $25,000/patient was utilized to calculate lifetime cost savings in patients receiving tPA. Results: During the study period, 776 AIS were admitted to our CSC (median age 64; 55,74, 51% men, 62% white). Seventy-six percent of our patients (n=590) had ≥1 tPA exclusions according to the NINDS trial. Among these patients, 11 excluded had history of ICH, 15 with recent strokes, and 1 both. Following the new package insert, the proportion of patients with ≥1 tPA exclusion fell to 73% (n=563). Given the 432,000 ischemic stroke discharges annually, a 3% increase in patients eligible for tPA could translate to treatment of 12,960 more patients annually and a lifetime cost savings of $324,000,000. Furthermore, we estimate that 1,685 of these newly eligible patients will experience a favorable functional outcome based on the results of the NINDS trial (13% shift analysis for mRS 0-1). Conclusions: Our results suggest that the new tPA package insert has the potential to increase national tPA treatment rates, decrease U.S. health care costs, and improve functional outcomes in eligible AIS patients. National guidelines need to be updated to reflect these changes.

scholarly journals Pseudoaneurisma Arteri Brakialis Pasca Kateterisasi Laporan Kasus

e-CliniC ◽  
2019 ◽  
Vol 7 (1) ◽  
Author(s):  
Natalia Ch. Polii ◽  
Janry A. Pangemanan ◽  
Agnes L. Panda ◽  
Ira Posangi
Keyword(s):  
Brachial Artery ◽  
Colour Doppler ◽  
Ultrasound Guided ◽  
Compression Technique ◽  
Artery Pseudoaneurysm ◽  
Neck Size ◽  
Chief Complaints ◽  
Pulsed Wave Doppler ◽  
History Of ◽  
The Right

Abstract: Post-catheterization PSA occurs at the site of arterial puncture followed by incomplete hemostasis. We reported a 63-year-old male visited the emergency department of Prof Dr. R. D. Kandou Hospital with chief complaints of swelling and severe pain on the right arm, occured 6 days prior to the ER visit. His right arm looked darker and felt colder than the counterpart, felt numb, and was hard to move due to pain. Three months ago, the patient had a history of percutaneous transluminal coronary angiography through brachial artery access. Examination of the right upper extremity revealed hematoma at brachial artery puncture site, edema at 1/3 distal of the brachial region, cold acral areas, strong right brachial artery pulses, yet small radial ones. Vascular Doppler examination showed a superficial hematoma above the brachial artery and a PSA pouch of 1.23 x 1.67 cm with a small neck (<0.5 cm). Colour Doppler displayed a “yin and yang” flow at pouch, while pulsed-wave Doppler showed a “to and fro” wave through the neck. Patient was diagnosed as iatrogenic brachial artery pseudoaneurysm and managed with ultrasound-guided compression technique followed by continuous compression with elastic bandage. This technique was selected due to the PSA size less than 3 cm yet symptomatic, small neck size (<1 cm), and no size progression. Patient discharged after the PSA pouch and neck shrinked. On 6 months follow-up, neither neck nor pseudoaneurysm pouch were found.Keywords: pseudoaneurysm, ultrasound-guided compression Abstrak: PSA pasca kateterisasi terjadi pada arteri yang dipungsi tetapi tidak terjadi hemostasis sempurna. Kami melaporkan seorang laki-laki berusia 63 tahun datang di Instalasi Rawat Darurat Medik RSUP Prof. Dr. R. D. Kandou dengan keluhan utama bengkak dan nyeri hebat pada lengan kanan sejak 6 hari SMRS dan memberat pada satu hari terakhir. Tangan kanan tampak lebih gelap dibandingkan tangan kiri, teraba dingin, terasa kebas dan sulit digerakkan karena nyeri. Tiga bulan sebelumnya pasien dilakukan tindakan intervensi koroner perkutan. Pada pemeriksaan ekstremitas atas kanan tampak hematoma di daerah pungksi, edema setinggi 1/3 distal regio brachialis sampai ujung jari, akral teraba dingin, pulsasi arteri brakialis teraba kuat tetapi arteri radialis teraba kecil. Pemeriksaan Doppler vascular mendapatkan gambaran hematoma superfisial dari arteri brakialis dan tampak kantong PSA berukuran 1,23x1,67 cm dengan neck berukuran kecil (<0,5 cm) Pada colour Doppler didapatkan aliran pada kantong pseudoaneurisma seperti gambaran yin dan yang. Pada pulsed-wave Doppler di saluran PSA (neck) didapatkan gelombang “to and fro”. Berdasarkan anamnesis, pemeriksaan fisik dan penunjang pasien ini didiagnosis dengan PSA arteri brakialis iatrogenik (pasca kateterisasi). Penanganan dengan ultrasound-guided compression dan dilanjutkan dengan kompresi kontinu dengan bebat elastik. Pemilihan teknik kompresi ini berdasarkan pada ukuran kantong <3 cm namun bergejala, ukuran neck kecil <1cm serta tidak didapatkan pembesaran progresif. Pasien dipulangkan setelah kantong maupun neck PSA tampak mengecil, dan 6 bulan setelahnya tidak lagi terlihat neck maupun kantong PSA.Kata kunci: pseudoaneurisma, ultrasound-guided compression

Sign in / Sign up

Export Citation Format

Share Document