scholarly journals Periodontal results of different therapeutic approaches (open vs. closed technique) and timing evaluation ( 2 year) of palatal impacted canines: a systematic review

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Rosanna Guarnieri ◽  
Serena Bertoldo ◽  
Michele Cassetta ◽  
Federica Altieri ◽  
Camilla Grenga ◽  
...  
Keyword(s):  
Primary Outcome ◽  
Risk Of Bias ◽  
Secondary Outcome ◽  
Therapeutic Approaches ◽  
Closed Technique ◽  
Impacted Canines ◽  
Cochrane Reviews ◽  
End Of Treatment ◽  
Impacted Canine ◽  
Bias Evaluation

Abstract Background This review evaluates, as a primary outcome, which surgical technique (open vs. closed) and which type of material used for the auxiliaries (elastic vs. metallic) were preferable in terms of periodontal results during the treatment of palatal-impacted canines. The timing of the evaluation of the results was also assessed as a secondary outcome. Methods An electronic search of the literature up to March 2021 was performed on Pubmed, MEDLINE (via Pubmed), EMBASE (via Ovid), Cochrane Reviews and Cochrane Register of Controlled Trials (RCTs) (CENTRAL). The risk of bias evaluation was performed using version 2 of the Cochrane risk of bias tool (RoB 2) for RCTs and the ACROBAT NRSI tool of Cochrane for non-RCTs. Results 11 articles met the inclusion criteria. Only one RCT was assessed as having a low risk of bias and all the non-RCTs were assessed as having a serious risk of bias. This review revealed better periodontal results for the closed technique and metallic auxiliaries. In addition, it revealed that the timing of the evaluation of the results affects the periodontal results with better results obtained 2 years after the end of treatment. Conclusion In the treatment of a palatal-impacted canine, the closed technique and metallic auxiliaries should be preferred in terms of better periodontal results. The timing of the evaluation of the results affects the periodontal results.

scholarly journals Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review

BMJ Open ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. e045343
Author(s):  
Ray Moynihan ◽  
Sharon Sanders ◽  
Zoe A Michaleff ◽  
Anna Mae Scott ◽  
Justin Clark ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Outcome ◽  
Unmet Need ◽  
Healthcare Utilisation ◽  
Healthcare Services ◽  
Risk Of Bias ◽  
Secondary Outcome ◽  
Severe Illness ◽  
Service Utilisation ◽  
Registration Number

ObjectivesTo determine the extent and nature of changes in utilisation of healthcare services during COVID-19 pandemic.DesignSystematic review.EligibilityEligible studies compared utilisation of services during COVID-19 pandemic to at least one comparable period in prior years. Services included visits, admissions, diagnostics and therapeutics. Studies were excluded if from single centres or studied only patients with COVID-19.Data sourcesPubMed, Embase, Cochrane COVID-19 Study Register and preprints were searched, without language restrictions, until 10 August, using detailed searches with key concepts including COVID-19, health services and impact.Data analysisRisk of bias was assessed by adapting the Risk of Bias in Non-randomised Studies of Interventions tool, and a Cochrane Effective Practice and Organization of Care tool. Results were analysed using descriptive statistics, graphical figures and narrative synthesis.Outcome measuresPrimary outcome was change in service utilisation between prepandemic and pandemic periods. Secondary outcome was the change in proportions of users of healthcare services with milder or more severe illness (eg, triage scores).Results3097 unique references were identified, and 81 studies across 20 countries included, reporting on >11 million services prepandemic and 6.9 million during pandemic. For the primary outcome, there were 143 estimates of changes, with a median 37% reduction in services overall (IQR −51% to −20%), comprising median reductions for visits of 42% (−53% to −32%), admissions 28% (−40% to −17%), diagnostics 31% (−53% to −24%) and for therapeutics 30% (−57% to −19%). Among 35 studies reporting secondary outcomes, there were 60 estimates, with 27 (45%) reporting larger reductions in utilisation among people with a milder spectrum of illness, and 33 (55%) reporting no difference.ConclusionsHealthcare utilisation decreased by about a third during the pandemic, with considerable variation, and with greater reductions among people with less severe illness. While addressing unmet need remains a priority, studies of health impacts of reductions may help health systems reduce unnecessary care in the postpandemic recovery.PROSPERO registration numberCRD42020203729.

Assessment of Safety of Remdesivir in Covid −19 Patients with Estimated Glomerular Filtration Rate (eGFR) < 30 ml/min per 1.73 m^2

2021 ◽  
pp. 088506662110705
Author(s):  
Shan Wang ◽  
Christy Huynh ◽  
Shahidul Islam ◽  
Brian Malone ◽  
Naveed Masani ◽  
...  
Keyword(s):  
Chart Review ◽  
Primary Outcome ◽  
Therapeutic Option ◽  
Kidney Injury ◽  
Retrospective Chart Review ◽  
Secondary Outcome ◽  
Oxygen Requirement ◽  
End Of Treatment ◽  
Review Study ◽  
T1 And T2

Purpose Safety of remdesivir in patients with renal impairment is unknown. Incidence of liver injury secondary to remdesivir is also unknown. The objective of this study is to assess the incidence of acute kidney injury (AKI) and to trend the liver enzymes during remdesivir treatment and change in eGFR from baseline to end of treatment as well as 48 h post completion of remdesivir therapy. Methods This is a retrospective chart review study including adult patients admitted with COVID-19 receiving remdesivir with a baseline eGFR < 30 ml/min per 1.73 m^2 from December 2020 to May 2021. The primary outcome was to assess the incidence of AKI and hepatic injury. The secondary outcome was to assess the efficacy of remdesivir defined by change in oxygen requirement. Results Seventy-one patients were included in the study. Patients experienced an improvement in eGFR from baseline (T0) to end of remdesivir treatment (T1), as well as 48 h after the end of the treatment (T2) ( + 30.3% and + 30.6% respectively, P < .0001). Creatinine reduced from baseline (T0) to T1 and T2 (-20.9% and −20.5% respectively, P < .0001). Creatinine clearance improved from baseline to T1 and T2 ( + 26.6% and + 26.2% respectively, p < .0001). Elevation of aminotransferase (AST) was observed at T1 ( + 2.5%, P  =  .727), however, AST reduction was seen at T2 (-15.8%, P  =  .021). Elevation in alanine transaminase (ALT) was observed at T1 and T2 ( + 25% and + 12%, P  =  .004 and P  =  .137 respectively). Both direct and total bilirubin remained stable and were not significantly changed from baseline. Conclusion Our study showed that remdesivir use in renally-impaired patients with eGFR < 30 ml/min is safe. Remdesivir may be considered as a therapeutic option in this population with COVID-19 infection.

P332Comparative efficacy of intracoronary agents for acute treatment of coronary no-reflow: a network meta-analysis

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Stibleichinger ◽  
J Wendt ◽  
F Hofbauer ◽  
G Klappacher
Keyword(s):  
Coronary Flow ◽  
Acute Treatment ◽  
Randomised Controlled Trials ◽  
Primary Outcome ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Secondary Outcome ◽  
No Reflow ◽  
Randomised Controlled

Abstract Background Coronary no-reflow is a potentially lethal complication of percutaneous coronary intervention (PCI). There is a growing body of evidence on how to best prevent this condition by the proper stenting technique and other mechanical measures or adjunctive drug treatments. However, it is still controversial how to tackle coronary no-reflow when it occurs. Purpose We aimed to compare and rank intracoronary agents for acute treatment of coronary no-reflow by considering both indirect and direct evidence from the literature in a network meta-analysis. Methods We searched the databases PubMed, Embase and Central for randomised controlled trials of the acute treatment of coronary no-reflow following primary PCI in patients with ST-elevation myocardial infarction (STEMI) and non-STEMI. Trials with patients suffering from stable angina and/or receiving elective PCI, observational study design and no measure of coronary flow were excluded. Two blinded reviewers independently collected studies, assessed risk of bias with the Cochrane risk of bias tool and extracted data. The primary outcome was a measure of coronary flow immediately following the intervention (TIMI flow grade, TIMI frame count or myocardial bush grade), secondary outcome were major adverse cardiovascular events during follow-up. Pairwise and network meta-analysis were performed using the random-effects model within a frequentist framework. Results 8 studies with a total of 540 participants were identified, including 4 multi-arm studies. This enabled 19 pairwise comparisons of 12 different treatments, all administered via intracoronary route (ADE=adenosine, DIL=diltiazem, DIP=dipyridamole, NIT= nitroglycerin, NPR=nitroprusside, PLA=placebo, TIR=tirofiban, U+V=urokinase combined with verapamil, URA=urapidil, URO=urokinase, VER=verapamil X+T= Xuesaitong combined with tirofiban). Overall, risk of bias in these studies was rated moderate. For graphical representation of the network for the primary outcome, see left panel of the figure. It exhibited a low level of inconsistency and heterogeneity with a global I2 value of 20.9%. Among the different treatments, URA, X+T, and TIR were more effective in re-establishing coronary flow with the caveat that the results of URA depended on one singular trail with a large variance, see right panel of the figure. NIT was even slightly worse than placebo in the primary outcome, the other agents were equivalent with placebo. In terms of major cardiovascular events during follow-up, TIR exhibited a protective effect compared with placebo at borderline statistical significance (OR 0.3843 [95% CI 0.1488; 0.9923]. For URA, data on secondary outcome were not available. Conclusions Urapidil and Tirofiban are potentially effective candidate drugs for larger randomised controlled trials, which are needed to validate the sparse evidence that is available to date on the acute treatment of coronary no-reflow.

scholarly journals Research Waste in ME/CFS

2017 ◽  
Author(s):  
Sonia Lee
Keyword(s):  
Odds Ratio ◽  
Primary Outcome ◽  
Risk Of Bias ◽  
Secondary Outcome ◽  
Selective Reporting ◽  
Research Waste ◽  
Research Areas ◽  
Data Practices ◽  
Design Selection ◽  
Operational Aspects

AbstractObjectiveTo compare the prevalence of selective reporting in ME/CFS research areas: psychosocial versus cellular.MethodA bias appraisal was conducted on three trials (1x psychosocial and 2x cellular) to compare risk of bias in study design, selection and measurement. The primary outcome compared evidence and justifications in resolving biases by proportions (%) and ORs (Odds Ratio); the secondary outcome determined the proportion (in %) of ME/CFS grants at risk of bias.ResultsNS (cellular study) was twice as likely to present evidence in resolving biases over PACE (psychosocial trial) (OR = 2.16; 65.6% vs 46. 9%), but this difference was not significant (p = 0.13). However, NS was five times more likely to justify biases over PACE (OR = 4.76; 46.9% vs 15. 6%) and this difference was significant (p = 0.0095; p < 0.05). PACE was weak in place (operational aspects 32%) and NS for data practices (37%). The proportion of grants were more biased in PACE (72%) than NS (28%) for evidence, and also more biased in PACE (86%) than NS (14%) for justifications.ConclusionPsychosocial trials on ME/CFS are more likely to engage in selective reporting indicative of research waste than cellular trials. Improvements to place may help reduce these biases, whereas cellular trials may benefit from adopting more translatable data methods. However, these findings are based on two trials. Further risk of bias appraisals are needed to determine the number of trials required to make robust these findings.

Rationale, baseline characteristics and methodology of the non-interventional VIVA study in postmenopausal osteoporosis

2014 ◽  
Vol 23 (01) ◽  
pp. 49-55
Author(s):  
L. C. Hofbauer ◽  
D. Felsenberg ◽  
M. Amling ◽  
A. Kurth ◽  
P. Hadji
Keyword(s):  
Quality Of Life ◽  
Postmenopausal Osteoporosis ◽  
Primary Outcome ◽  
Osteoporosis Treatment ◽  
Secondary Outcome ◽  
Matched Pairs ◽  
Fracture History ◽  
Baseline Characteristics ◽  
Study Inclusion

SummaryIt is important to understand compliance and persistence with medication use in the clinical practice of osteoporosis treatment. The purpose of this work is to describe the “intravenous ibandronate versus oral alendronate” (VIVA) study, a non-interventional trial to assess the compliance and persistence of osteopenic postmenopausal women with treatment via weekly oral alendronate or intravenous ibandronate (Bonviva®) every three months.4477 patients receiving ibandronate 3 mg i. v. quarterly and 1491 patients receiving alendronate 70 mg orally weekly were included in the study. Matched pairs of 901 subjects in each group were also generated. Matching was performed on the basis of age, body mass index, fracture history at study inclusion, prior treatment with bisphosphonates and the number of concomitant disorders. Secondary outcome measures of osteoporosis related fractures, mobility restriction and pain, analgesia, quality of life questionnaires as well as attitudes to medications were assessed. The primary outcome parameters of compliance and persistence will be tracked in these subjects.At baseline, the entire collectives differed significantly on body weight (less in ibandronate group), duration since osteo - porosis diagnosis (longer in ibandronate), and incidence of prior osteoporotic fracture (higher in ibandronate group). The matched-pairs differed only on mobility restriction and quality of life (both worse in ibandronate group).The results from the VIVA study trial will provide scientific rationale for clinical recommendations in the pharmacological treatment of postmenopausal osteoporosis.

Patient Tolerability of Bowel Preparation is Associated with Polyp Detection Rate During Colonoscopy

2014 ◽  
Vol 23 (2) ◽  
pp. 135-140 ◽  
Author(s):  
Edward W. Holt ◽  
Kidist K. Yimam ◽  
Hanley Ma ◽  
Richard E. Shaw ◽  
Richard A. Sundberg ◽  
...  
Keyword(s):  
Bowel Preparation ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Polyp Detection ◽  
Cross Sectional ◽  
Quality Outcomes ◽  
Negative Experience ◽  
Polyp Detection Rate ◽  
Patient Reported ◽  
Bowel Prep

Background & Aims: A number of factors have been identified that influence the yield of screeningcolonoscopy. The perceived tolerability of bowel preparation has not been studied as a predictor of quality outcomes in colonoscopy. We aimed to characterize the association between patient-perceived tolerability of bowel preparation and polyp detection during colonoscopy.Methods: We performed a cross-sectional cohort study of 413 consecutive adult patients presenting foroutpatient colonoscopy at two outpatient endoscopy centers at our institution. We developed a standardized questionnaire to assess the patient's experience with bowel preparation. Bowel preparation quality was measured using the validated Ottawa scale and colonoscopic findings were recorded for each patient. The primary outcome was polyp detection and the secondary outcome was the quality of bowel preparation.Results: Patient-reported clarity of effluent during bowel preparation correlated poorly with Ottawa score during colonoscopy, k=0.15. Female gender was an independent risk factor for a poorly tolerated bowel prep (OR 3.93, 95% CI 2.30 - 6.72, p<0.001). Report of a poorly tolerated bowel prep was independently associated with the primary outcome, polyp detection (OR 0.39, 95% CI 0.18 - 0.84, p=0.02) and also with the secondary outcome, lower quality bowel preparation (OR 2.39, 95% CI 1.17 - 4.9, p=0.02).Conclusions: A patient-perceived negative experience with bowel preparation independently predicted both a lower quality bowel preparation and a lower rate of polyp of detection. Assessment of the tolerability of bowel preparation before colonoscopy may be a clinically useful predictor of quality outcomes during colonoscopy.

scholarly journals 57. Evaluating the Utility of a Penicillin Allergy Reconciliation Program within an Infectious Diseases Consult Population in a Community Health System

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S49-S50
Author(s):  
Bruce M Jones ◽  
Emily Plauche ◽  
Susan E Smith ◽  
Christopher M Bland
Keyword(s):  
Infectious Diseases ◽  
Health System ◽  
Community Health ◽  
Intervention Program ◽  
Primary Outcome ◽  
Panel Member ◽  
Penicillin Allergy ◽  
Secondary Outcome ◽  
Research Support ◽  
Research Grant

Abstract Background Penicillin allergy reconciliation is an important aspect of antimicrobial stewardship with ~10% of the population reporting a penicillin allergy. Our facility utilizes a Penicillin Allergy Reconciliation Program (PARP) led by an Infectious Diseases (ID) Pharmacist and pharmacy students to identify patients with penicillin allergies to reconcile and intervene when necessary. Information is collected by interview, electronic medical record (EMR) review, prescription outpatient fill history. This study evaluated reconciliations with and without a PARP in patients in a community health system. Methods This was a retrospective study that compared reconciliations performed on adult patients admitted at least once in 2019 with a self-reported penicillin allergy and ID physician consult at a hospital with a PARP (Institution 1) and one without a formal evaluation and intervention program (Institution 2) within the same community health system with same ID physicians. The primary outcome was documented reconciliation of a patient’s penicillin allergy during an inpatient visit in 2019. Reconciliation was defined as an edit or clarification (updating the severity, reaction, or comments section, as well as deleting) to a patient’s penicillin allergy in the EMR. The secondary outcome evaluated the percentage of total and ID consult patients with a penicillin allergy. Results There were 245 patients who met criteria and were included in the study, 113 from Institution 1 and 132 from Institution 2. For the primary outcome, there were 82 (72.6%) reconciliations at Institution 1 and 15 (11.4%) reconciliations at Institution 2 (p &lt; 0.001). Interventions at Institution 1 and 2 resulted in 74 EMR updates and 8 removals and 14 EMR updates and 1 removal, respectively. Reconciliation was performed on the same visit as the ID consult in 59/82 patients (72%) at Institution 1 and 11/15 patients (73.3%) at Institution 2. All reconciliations at Institution 2 were made by pharmacist (10) or nurses (5). For the secondary outcome, 10.9% of patients with an ID consult and 12.6% of all patients admitted in 2019 had a penicillin allergy (p=0.027). Conclusion A PARP led by an ID pharmacist and students was an effective method to perform penicillin allergy reconciliations, even in the presence of active ID consultation. Disclosures Bruce M. Jones, PharmD, BCPS, ALK-Abello (Research Grant or Support)Allergan/Abbvie (Speaker’s Bureau) Christopher M. Bland, PharMD, FCCP, FIDSA, BCPS, ALK Abello, Inc. (Grant/Research Support)Biomerieux (Consultant)Merck (Consultant, Grant/Research Support, Advisor or Review Panel member, Speaker’s Bureau)Tetraphase (Speaker’s Bureau)

Comparative study of intracranial access in thrombectomy using next generation 0.088 inch guide catheter technology

2021 ◽  
pp. neurintsurg-2021-017341
Author(s):  
Devin V Bageac ◽  
Blake S Gershon ◽  
Jan Vargas ◽  
Maxim Mokin ◽  
Zeguang Ren ◽  
...  
Keyword(s):  
Primary Outcome ◽  
Primary Outcome Measure ◽  
Secondary Outcome ◽  
Control Group ◽  
Anterior Circulation ◽  
Guide Catheter ◽  
Catheter Failure ◽  
Catheter Technology ◽  
Intracranial Vasculature

BackgroundMost conventional 0.088 inch guide catheters cannot safely navigate intracranial vasculature. The objective of this study is to evaluate the safety of stroke thrombectomy using a novel 0.088 inch guide catheter designed for intracranial navigation.MethodsThis is a multicenter retrospective study, which included patients over 18 years old who underwent thrombectomy for anterior circulation large vessel occlusions. Technical outcomes for patients treated using the TracStar Large Distal Platform (TracStar LDP) or earlier generation TRX LDP were compared with a matched cohort of patients treated with other commonly used guide catheters. The primary outcome measure was device-related complications. Secondary outcome measures included guide catheter failure and time between groin puncture and clot engagement.ResultsEach study arm included 45 patients. The TracStar group was non-inferior to the control group with regard to device-related complications (6.8% vs 8.9%), and the average time to clot engagement was 8.89 min shorter (14.29 vs 23.18 min; p=0.0017). There were no statistically significant differences with regard to other technical outcomes, including time to recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2B). The TracStar was successfully advanced into the intracranial internal carotid artery in 33 cases (73.33%); in three cases (6.67%), it was swapped for an alternate catheter. Successful reperfusion (mTICI 2B-3) was achieved in 95.56% of cases. Ninety-day follow-up data were available for 86.67% of patients, among whom 46.15% had an modified Rankin Score of 0–2%, and 10.26% were deceased.ConclusionsTracstar LDP is safe for use during stroke thrombectomy and was associated with decreased time to clot engagement. Intracranial access was regularly achieved.

Association between Dietary Inflammatory Index and kidney stones in US adults: Data from the NHANES 2007-2016

2021 ◽  
pp. 1-27
Author(s):  
Chichen Zhang ◽  
Shi Qiu ◽  
Haiyang Bian ◽  
Bowen Tian ◽  
Haoyuan Wang ◽  
...  
Keyword(s):  
National Health ◽  
Kidney Stones ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Nutrition Examination Survey ◽  
Dietary Inflammatory Index ◽  
Inflammatory Index ◽  
Health And Nutrition ◽  
Multivariate Adjustment ◽  
Increased Risk

Abstract Objective: We evaluate the association between the Dietary Inflammatory Index (DII) and kidney stones. Design: We performed a cross-sectional analysis using data from National Health and Nutrition Examination Survey. Dietary intake information was assessed using first 24-HR dietary recall interviews, and the Kidney Conditions was presented by questionnaire. The primary outcome was to investigate the association between DII and incidence of kidney stones, and the secondary outcome was to assess the association between DII and nephrolithiasis recurrence. Setting: The National Health and Nutrition Examination Survey (NHANES), 2007-2016. Participants: The study included 25984 NHANES participants, whose data on DII and kidney stones were available, of whom 2439 reported a history of kidney stones. Results: For the primary outcome, after fully multivariate adjustment, DII score is positively associated with the risk of kidney stones (OR = 1.07; 95% CI: [1.04–1.10]). Then, compared Q4 with Q1, a significant 38% increased likelihood of nephrolithiasis was observed. (OR=1.38; 95% CI: [1.19–1.60]). For the secondary outcome, the multivariate regression analysis showed that DII score is positively correlated with nephrolithiasis recurrence (OR=1.07; 95% CI: [1.00–1.15]). The results noted that higher DII scores (Q3 and Q4) are positively associated with a significant 48% and 61% increased risk of nephrolithiasis recurrence compared with the reference after fully multivariate adjustment. (OR=1.48; 95% CI: [1.07–2.05]; OR=1.61; 95% CI: [1.12–2.31]). Conclusions: Our findings revealed that increased intake of pro-inflammatory diet, as a higher DII score, is correlated with increased odds of kidney stones incidence and recurrence.

scholarly journals The Impact of Time Interval between Hepatic Resection and Liver Transplantation on Clinical Outcome in Patients with Hepatocellular Carcinoma

Cancers ◽  
2021 ◽  
Vol 13 (10) ◽  
pp. 2398
Author(s):  
Matteo Serenari ◽  
Enrico Prosperi ◽  
Marc-Antoine Allard ◽  
Michele Paterno ◽  
Nicolas Golse ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Liver Transplantation ◽  
Hepatic Resection ◽  
Primary Outcome ◽  
Polynomial Regression ◽  
Secondary Outcome ◽  
Time Interval ◽  
Comprehensive Complication Index ◽  
Fractional Polynomial ◽  
The Impact

Hepatic resection (HR) for hepatocellular carcinoma (HCC) may require secondary liver transplantation (SLT). However, a previous HR is supposed to worsen post-SLT outcomes. Data of patients treated by SLT between 2000 and 2018 at two tertiary referral centers were analyzed. The primary outcome of the study was to analyze the impact of HR on post-LT complications. A Comprehensive Complication Index ≥ 29.6 was chosen as cutoff. The secondary outcome was HCC-related death by means of competing-risk regression analysis. In the study period, 140 patients were included. Patients were transplanted in a median of 23 months after HR (IQR 14–41). Among all the features analyzed regarding the prior HR, only time interval between HR and SLT (time HR-SLT) was an independent predictor of severe complications after LT (OR = 0.98, p < 0.001). According to fractional polynomial regression, the probability of severe complications increased up to 15 months after HR (43%), then slowly decreased over time (OR = 0.88, p < 0.001). There was no significant association between HCC-related death and time HR-SLT at the multivariable competing risks regression model (SHR, 1.06; 95% CI: 0.69–1.62, p = 0.796). This study showed that time HR-SLT was key in predicting complications after LT, without affecting HCC-related death.

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