Preoperative Sucrosomial Iron Supplementation Increases Haemoglobin and Reduces Transfusion Requirements in Elective Heart Surgery Patients: A Prospective Randomized Study

Background: Low preoperative haemoglobin is frequently observed in heart surgery patients and is associated with a significant decrease in haemoglobin between post-operative days 2 and 3, known as haemoglobin drift. Overall, these patients tend to receive many RBC transfusions. Since iron homeostasis is often impaired in these patients, restoration of iron availability might override iron-restricted erythropoiesis. However, reduced tolerance to oral iron salts has limited this strategy to intravenous iron administration. Study Design and Methods: The purpose of this study was to assess whether preoperative supplementation with oral sucrosomial iron, a new iron-delivery technology with improved tolerance and bioavailability, might be an effective strategy for this patient population. One thousand consecutive patients were randomized and received either a one-month course of sucrosomial iron (60 mg/day) or no treatment prior to elective heart surgery at a single high-volume centre (ClinicalTrials.gov NCT03560687). Primary end-points were haemoglobin concentration on the day of hospital admittance and number of blood transfusions. Secondary end-points were haemoglobin drift, tolerance of treatment and cost-effectiveness of sucrosomial iron administration. Results: Baseline haemoglobin in the treatment group was higher (by 0.67 g/dL; p<0.001) than that in the control group. The percentage of patients in the treatment group who required transfusion (35.4%) was half that in the control group (64.6%). The average number of transfused units per operation was 0.95 vs. 2.03 in the treatment and control groups, respectively. Haemoglobin drift was substantially similar in the two groups, and the tolerability of treatment was excellent (98%). The overall cost of treatment was 156 Euros less in the treatment group, expressed as a raw cost of transfusion. Conclusion: In elective heart surgery, routine preoperative sucrosomial iron administration seems to be a safe, well-tolerated and cost-effective strategy to increase preoperative haemoglobin and reduce the need for allogeneic blood transfusions.

Download Full-text

Haematological Presentations in Acute and Chronic Tramadol Intoxication

Toxicology and Forensic Medicine - Open Journal ◽

10.17140/tfmoj-5-134 ◽

2020 ◽

Vol 5 (1) ◽

pp. 26-36

Author(s):

Loveday U. Zebedee ◽

◽

Owubokiri N. Jeremiah ◽

Anthony E. Soroh ◽

Eni-yimini S. Agoro ◽

...

Keyword(s):

Treatment Group ◽

Normal Saline ◽

Blood Count ◽

Saline Solution ◽

Lethal Dose ◽

Haemoglobin Concentration ◽

Chronic Phase ◽

Male Rats ◽

Full Blood Count ◽

Control Group

Introduction Tramadol is a synthetic centrally acting analgesic used worldwide for pain relief, but now abused as a euphoria generating substance. The short- and long-term implications of tramadol intoxication on blood cells and its components are still hazy and controversial. Aim Our primary aim was to evaluate the alterative pattern of haematological parameters resulting from acute or chronic tramadol intoxication. Method The study was made of acute and chronic phases of sixty male rats (Rattusnorvegicus) randomly pair-divided into established groups of six male rats each. The acute stage consisted of a control group of 6 rats administered with normal saline solution, and a treatment group of 6 rats administered with lethal dose of tramadol. The control group for the chronic stage consisted of 6 rats that were administered normal saline solution. Whereas, the tramadol-dependent groups comprised of 3 groups of 6 rats each administered orally with 50 mg/kg, 100 mg/kg, and 200 mg/kg of tramadol for 90 days respectively. Statistical analyses consisted of the one-way analysis of variance (ANOVA), Student’s t-test, and Pearson’s Correlation using the JMP statistical discovery™ software version 14.1. Blood samples were collected after anesthetic sacrifice by cardiac puncture for the analysis of full blood count and red cell indices using SYSMEX Automated Blood Count machine (SYSMEX KX-21N ANALYZER) and microscopy for blood film reading. Results Results of the acute phase of the study showed that the packed cell volume (PCV) in the treatment group (51.00±2.96%) was significantly higher (t=3.99, p=0.002) than control (37.83±1.43%). Similarly, the haemoglobin concentration (Hb) in the treatment group (14.70±0.46 g/dL) was significantly higher (t=5.10, p=0.005) than control (11.55±0.41 g/dL). The mean cell haemoglobin concentration (MCHC) was significantly lower (t=2.67, p=0.02) in the control group (28.30±0.52 g/dL) than treatment (30.43±0.61 g/dL). However, that of the chronic phase exhibited a progressive increase in platelet count which was proportional to increasing dosage of treatment (t=8.59, p=0.007). Conclusion This study has demonstrated that tramadol administration could cause haematological alterations which could be beneficial if administrated optimally and deleterious, if abused. Therefore, indiscriminate and prolonged use of tramadol should be monitored to avert haemotoxicity.

Download Full-text

Effects of Remifentanil and Sufentanil Anesthesia on Cardiac Function and Serological Parameters in Congenital Heart Surgery

Journal of Healthcare Engineering ◽

10.1155/2021/4650291 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Zhigang Qin ◽

Younian Xu

Keyword(s):

Congenital Heart Disease ◽

Heart Disease ◽

Treatment Group ◽

Cardiac Function ◽

Congenital Heart ◽

Heart Surgery ◽

Congenital Heart Surgery ◽

Control Group ◽

Muscle Rigidity ◽

Significant Difference

In this study, we have investigated feasibility of remifentanil and sufentanil anesthesia in children with congenital heart disease surgery and its effects on cardiac function and serological parameters. For this purpose, a retrospective study was conducted on 120 children with congenital heart disease who underwent repair of ventricular septum or atrial septum in our hospital, specifically from January 2016 to January 2018, and 60 patients in each group were randomly divided into the control and treatment groups, respectively. The control group was anesthetized with sufentanil, and the treatment group was anesthetized with remifentanil. The heart function, serological indexes, and adverse reactions were observed and compared. We have observed that there was no significant difference in HR levels between these groups ( P > 0.05 ), but SDP and DBP values of the two groups were decreased after anesthetic induction ( P < 0.05 ). ACH, cortisol, and lactic acid in the treatment group were significantly lower than those in the control group, and the difference was statistically significant ( P < 0.05 ). The incidence of bradycardia, nausea and vomiting, hypotension, muscle rigidity, and respiratory depression in the treatment group was 16.67% lower than that in the control group ( P < 0.05 ). Remifentanil has less influence on hemodynamics and a better analgesic effect than fentanyl in inhibiting stress response in congenital heart surgery, which provides reference and basis for children congenital heart surgery.

Download Full-text

Haematological Indices in Trypanosoma Brucei Brucei (Federe Isolate) Infected Nigerian Donkeys (Equus Asinus) Treated with Homidium and Isometamidium Chloride

Macedonian Veterinary Review ◽

10.1515/macvetrev-2017-0014 ◽

2017 ◽

Vol 40 (1) ◽

pp. 73-82 ◽

Cited By ~ 2

Author(s):

Queen Nneka Oparah ◽

Anthony Bedu kojo Sackey ◽

Idris Alao Lawal ◽

Usman Shehu Abdullahi

Keyword(s):

Treatment Group ◽

Post Infection ◽

Haemoglobin Concentration ◽

Chloride Ion ◽

Negative Control Group ◽

Positive Control ◽

Negative Control ◽

Control Group ◽

Treatment Groups ◽

Equus Asinus

Abstract The efficacy of intramuscular administration of Homidium chloride (Novidium®) and Isometamidium chloride (Sécuridium®) in Nigerian donkeys (Equus asinus) experimentally infected with T. b. brucei (Federe isolate) was investigated. Changes in haematological and serum biochemical indices were evaluated using clinical haematology and biochemistry methods. Red blood cell (RBC) count for the negative control group was significantly higher than for the positive control, Novidium® and Sécuridium®-treatment groups. Haemoglobin (Hb) concentration significantly reduced in the infected untreated group compared with other groups. Packed cell volume (PCV) was significantly different between negative and positive controls, and also between the infected untreated and treatment groups. There was significant reduction in platelet counts post-infection and post-treatment. Mean corpuscular volume (MCV) increased significantly in the treatment groups while mean corpuscular haemoglobin concentration (MCHC) significantly reduced only in the Sécuridium®-treatment group. Lymphocyte count for infected untreated was non-significantly higher than for the uninfected controls, but treatment with both trypanocides recorded further increases, which were higher compared with that of the uninfected group. Post infection and treatment, aspartate aminotransferase (AST) levels increased significantly. There were non-significant differences in electrolyte ion concentrations across the groups except for chloride ion which recorded a significant reduction in the Novidium®-treatment group. This experiment revealed that Nigerian donkeys infected with T. brucei brucei (Federe isolate) developed symptoms of trypanosomosis; anaemia, lymphocytosis and thrombocytopenia. Treatment with the trypanocides ameliorated effects of the infection, and results suggest that immunosuppression may not be a substantial clinical manifestation of T. brucei brucei (Federe isolate) trypanosomosis in Nigerian donkeys.

Download Full-text

Role of terminal warm blood cardioplegia in complex congenital heart surgery

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492318759105 ◽

2018 ◽

Vol 26 (3) ◽

pp. 196-202 ◽

Cited By ~ 1

Author(s):

Pribadi Wiranda Busro ◽

Harvey Romolo ◽

Sudigdo Sastroasmoro ◽

Jusuf Rachmat ◽

Mohammad Sadikin ◽

...

Keyword(s):

Treatment Group ◽

Myocardial Protection ◽

Caspase 3 ◽

Heart Surgery ◽

Troponin I ◽

Congenital Heart Surgery ◽

Control Group ◽

Blood Cardioplegia ◽

Warm Blood ◽

Warm Blood Cardioplegia

Introduction Myocardial protection is vital to ensure successful open heart surgery. Cardioplegic solution is one method to achieve good myocardial protection. Inevitably, ischemia-reperfusion injury occurs with aortic crossclamping. Histidine-tryptophan-ketoglutarate solution is a frequently used cardioplegia for complex congenital heart surgery. We postulated that addition of terminal warm blood cardioplegia before removal of the aortic crossclamp might improve myocardial protection. Method A randomized controlled trial was conducted on 109 cyanotic patients aged, 1 to 5 years who underwent complex biventricular repair. They were divided into a control group of 55 patients who had histidine-tryptophan-ketoglutarate only and a treatment group of 54 who had histidine-tryptophan-ketoglutarate with terminal warm blood cardioplegia. Endpoints were clinical parameters, troponin I levels, and caspase-3 as an apoptosis marker. Results The incidence of low cardiac output syndrome was 34%, with no significant difference between groups (35.2% vs. 33.3%, p = 0.84). The incidence of arrhythmias in our treatment group was lower compared to the control group (36% vs. 12%, p = 0.005). Troponin I and caspase-3 results did not show any significant differences between groups. For cases with Aristotle score ≥ 10, weak expression of caspase-3 in the treatment group post-cardiopulmonary bypass was lower compared to the control group. Conclusion For complex congenital cardiac surgery, the addition of terminal warm blood cardioplegia does not significantly improve postoperative clinical or metabolic markers.

Download Full-text

Evaluation of tranexamic acid in reducing blood loss and transfusions in total knee replacement

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20193832 ◽

2019 ◽

Vol 5 (5) ◽

pp. 899

Author(s):

Mirza Atif Baig ◽

Srujith Kommera

Keyword(s):

Blood Loss ◽

Total Knee Replacement ◽

Tranexamic Acid ◽

Knee Replacement ◽

Acid Group ◽

Control Group ◽

Blood Transfusions ◽

Reduce Blood Loss ◽

Transfusion Requirements ◽

Total Knee

Background: Total knee replacement (TKR) is associated with substantial blood loss and thus the need for blood transfusions. Risks and costs of allogenic blood transfusions requires strategies to reduce blood loss in surgery. The objective of this study was to assess the efficacy of tranexamic acid treatment in reducing blood loss and blood transfusion requirements during TKR.Methods: A randomized controlled trial was conducted on 60 patients who were operated for unilateral TKR from January 2016 to January 2019 in Shadan Institute of Medical Sciences. 30 patients were in each control and study groups. In study group 12 mg/kg bolus of tranexamic acid was given as a slow IV dose, 40 minutes before deflation of tourniquet followed by 1.2 mg/kg/hr infusion for 12 hours with standard treatment of hospital and compared to the control group. Later blood loss was compared both intra and post operatively. Fall in haemoglobin after surgery was also compared.Results: Total blood loss in tranexamic acid group was 543.3±184.85 ml (control group 685.83±176.74 ml) which is statistically significant (p<0.05). Blood loss was markedly decreased in tranexamic acid group (379.16±174 ml in tranexamic acid vs. 513.33±143.89 ml in control group) statistically significant (p<0.05).Conclusions: Tranexamic acid is an effective strategy to reduce blood loss in patients undergoing total knee replacement and thus minimizing the need for blood transfusions.

Download Full-text

Modified Ultrafiltration Reduces Morbidity After Adult Cardiac Operations

Circulation ◽

10.1161/circ.104.suppl_1.i-253 ◽

2001 ◽

Vol 104 (suppl_1) ◽

Author(s):

Giovanni Battista Luciani ◽

Tiziano Menon ◽

Barbara Vecchi ◽

Stefano Auriemma ◽

Alessandro Mazzucco

Keyword(s):

Cardiopulmonary Bypass ◽

Hospital Stay ◽

Heart Surgery ◽

Open Heart Surgery ◽

Group Versus ◽

Control Group ◽

Continuous Variables ◽

Transfusion Requirements ◽

The Impact ◽

Cardiac Operations

Background Extracorporeal circulation contributes to morbidity after open-heart surgery by causing a systemic inflammatory reaction. Modified ultrafiltration is a technique able to remove the fluid overload and inflammatory mediators associated with use of cardiopulmonary bypass. It has been shown to reduce morbidity after cardiac operations in children, but the impact on adult cardiac procedures is unknown. Methods and Results Five hundred seventy-three consecutive adult patients were prospectively randomized to either ultrafiltration after cardiopulmonary bypass (treatment) or to no ultrafiltration (control). Parsonnet score was used to assess the severity of the patients’ clinical conditions. Analysis was done with Student’s t test or Mann-Whitney U test for continuous variables and Fisher’s exact test or Pearson’s χ 2 for discrete variables. Hospital mortality was 2.5% (7 of 284) in the treatment group versus 3.8% (11 of 289) in the control group ( P =0.357). Hospital morbidity was lower in treated patients (66 of 284 [23.2%] versus 117 of 289 [40.5%], P =0.0001). Cardiac morbidity was similar (26 of 284 [9.1%] versus 35 of 289 [12.1%], P =0.251), whereas significantly lower rates of respiratory (20 of 284 [7.0%] versus 36 of 289 [12.5%], P =0.029), neurological (5 of 284 [1.8%] versus 14 of 289 [4.8%], P =0.039), and gastrointestinal (0 of 284 versus 4 of 289 [1.4%], P =0.044) complications were found in treated patients. Transfusion requirements were also lower in treated patients (1.66±2.6 versus 2.25±3.8 U/patient, P =0.039). Duration of intensive care (39.9±49.2 versus 46.3±72.8 hours, P =0.218) and hospital stay (7.6±3.5 versus 7.9±4.4 days, P =0.372) were comparable. Conclusions Modified ultrafiltration after cardiopulmonary bypass is associated with a lower prevalence of early morbidity and lower blood transfusion requirements. The impact on length of hospital stay needs further analysis. Routine application of modified ultrafiltration after adult cardiac operations is warranted.

Download Full-text

Effect of Single Recombinant Human Erythropoietin Injection on Transfusion Requirements in Preoperatively Anemic Patients Undergoing Valvular Heart Surgery

Anesthesiology ◽

10.1097/aln.0b013e318232004b ◽

2011 ◽

Vol 115 (5) ◽

pp. 929-937 ◽

Cited By ~ 102

Author(s):

Young-Chul Yoo ◽

Jae-Kwang Shim ◽

Jong-Chan Kim ◽

Youn-Yi Jo ◽

Jong-Hoon Lee ◽

...

Keyword(s):

Heart Surgery ◽

Transfusion Requirement ◽

Reticulocyte Count ◽

Controlled Trial ◽

Group Versus ◽

Conservation Strategy ◽

Control Group ◽

Preoperative Anemia ◽

Human Erythropoietin ◽

Transfusion Requirements

Background The authors investigated the effect of a single preoperative bolus of erythropoietin on perioperative transfusion requirement and erythropoiesis in patients with preoperative anemia undergoing valvular heart surgery. Methods In this prospective, single-site, single-blinded, randomized, and parallel-arm controlled trial, 74 patients with preoperative anemia were randomly allocated to either the erythropoietin or the control group. The erythropoietin group received 500 IU/kg erythropoietin and 200 mg iron sucrose intravenously 1 day before the surgery. The control group received an equivalent volume of normal saline. The primary endpoint was transfusion requirement assessed during the surgery and for 4 days postoperatively. Reticulocyte count and iron profiles were measured serially and compared preoperatively and on postoperative days 1, 2, 4, and 7. Results Transfusion occurred in 32 patients (86%) of the control group versus 22 patients (59%) of the erythropoietin group (P = 0.009). The mean number of units of packed erythrocytes transfused per patient during the surgery and for 4 postoperative days (mean ± SD) was also significantly decreased in the erythropoietin group compared with the control group (3.3 ± 2.2 vs.. 1.0 ± 1.1 units/patient, P = 0.001). The reticulocyte count was significantly greater in the erythropoietin group at postoperative days 4 (P = 0.001) and 7 (P = 0.001). Conclusions A single intravenous administration of erythropoietin and an iron supplement 1 day before surgery significantly reduced the perioperative transfusion requirement in anemic patients undergoing valvular heart surgery, implicating its potential role as a blood conservation strategy.

Download Full-text

Ankaferd Blood Stopper Decreases Postoperative Bleeding and Number of Transfusions in Patients Treated with Clopidogrel: A Double-blind, Placebo-controlled, Randomized Clinical Trial

The Heart Surgery Forum ◽

10.1532/hsf.1256 ◽

2015 ◽

Vol 18 (3) ◽

pp. 118 ◽

Cited By ~ 7

Author(s):

Mehmet Besir Akpinar ◽

Atakan Atalay ◽

Hakan Atalay ◽

Omer Faruk Dogan

Keyword(s):

Heart Surgery ◽

Bypass Graft ◽

Postoperative Bleeding ◽

Open Heart Surgery ◽

Control Group ◽

Severe Bleeding ◽

Total Blood ◽

Transfusion Requirements ◽

Ankaferd Blood Stopper ◽

Cabg Patients

Background: The risk of reoperation due to bleeding after open heart surgery is 2.2%-4.2%. Patients who undergo reoperation have a two to six times greater mortality rate. Risk factors for reoperation include: older age, low body mass index, time on extracorporeal circulation, and emergency operations. In coronary artery bypass graft (CABG) patients who are treated preoperatively with antiplatelets, including clopidogrel, the source of postoperative bleeding may be difficult to detect. The aim of this study was to investigate the effectiveness of local Ankaferd blood stopper (ABS) to prevent mediastinal bleeding in CABG patients who were treated with clopidogrel and acetylsalicylic acid (ASA) preoperatively. Methods: Twenty-five emergency CABG patients premedicated with clopidogrel and ASA as antiplatelet drugs were included in the study (Group 1). An additional twenty-five patients who were premedicated with the same antiplatelet agents were selected as a control group (Group 2). Preoperative clinical characteristics of the two groups were comparable. At the end of the surgery, 4-10 mL of ABS solution was sprayed on the mediastinal and epicardial tissue following protamine administration in Group1. We compared postoperative total mediastinal bleeding, reoperation rate and total blood and blood products transfused between the two groups. Results: There was no mortality in either of the two groups. Mean postoperative bleeding was 430 mL in the ABS group, and 690 mL in the CG group (P = .044). In the ICU, bleeding in groups 1 and 2 was 610 mL and 980 mL, respectively (P = .025); total bleeding from the mediastinum was 830 mL and 1490 mL, respectively (P = .001) and the amount of autotransfusion was 210 mL and 400 mL (P = .003). Total transfusion of PRBCs in the operating room in groups 1 and 2 was 0.3 and 0.8, respectively (P = .003). No patients in the ABS group needed surgical revision due to severe bleeding or cardiac tamponade. Conclusion: The use of local ABS reduces bleeding, transfusion requirements of packed red blood cells, platelets and total blood units in patients premedicated with clopidogrel and ASA undergoing emergent CABG .

Download Full-text

A Newspaper’s Effect on the Strength of Automatic Associations in Memory

Journal of Media Psychology Theories Methods and Applications ◽

10.1027/1864-1105/a000057 ◽

2012 ◽

Vol 24 (1) ◽

pp. 1-8 ◽

Cited By ~ 12

Author(s):

Florian Arendt

Keyword(s):

Treatment Group ◽

Term Effect ◽

Control Group ◽

Implicit Measure ◽

Short Term ◽

Short Term Treatment ◽

Short Term Effect ◽

Automatic Associations ◽

Foreign Nationality ◽

The Impact

A test was done to see if reading a newspaper which consistently overrepresents foreigners as criminals strengthens the automatic association between foreign country and criminal in memory (i.e., implicit cultivation). Further, an investigation was done to find out if reading articles from the same newspaper produces a short-term effect on the same measure and if (1) emotionalization of the newspaper texts, (2) emotional reactions of the reader (indicated by arousal), and (3) attributed text credibility moderate the short-term treatment effect. Eighty-five participants were assigned to one of three experimental conditions. Participants in the control group received short factual crime texts, where the nationality of the offender was not mentioned. Participants in the factual treatment group received the same texts, but the foreign nationality was mentioned. Participants in the emotionalized treatment group received emotionalized articles (i.e., texts which are high in vividness and frequency) covering the same crimes, with the foreign nationality mentioned. Supporting empirical evidence for implicit cultivation and a short-term effect was found. However, only emotionalized articles produced a short-term effect on the strength of the automatic association, indicating that newspaper texts must have a minimum of stimulus intensity to overcome an effect threshold. There were no moderating effects of arousal or credibility pertaining to the impact on the implicit measure. However, credibility moderated the short-term effect on a first-order judgment (i.e., estimated frequency of foreigners of all criminals). This indicates that a newspaper’s effect on the strength of automatic associations is relatively independent from processes of propositional reasoning.

Download Full-text

Perbandingan Efek Suplementasi Tablet Tambah Darah Dengan Dan Tanpa Vitamin C Terhadap Kadar Hemoglobin Pada Ibu Hamil Dengan Usiakehamilan 16-32 Minggu Di Desa Keniten Kecamatan Mojo Kabupaten Kediri

Jurnal Ilmu Kesehatan ◽

10.32831/jik.v3i1.49 ◽

2017 ◽

Vol 3 (1) ◽

pp. 76

Author(s):

Siti Asiyah ◽

Dwi Estuning Rahayu ◽

Wiranti Dwi Novita Isnaeni

Keyword(s):

Treatment Group ◽

Vitamin C ◽

Gestational Age ◽

Group Treatment ◽

Sampling Technique ◽

Hemoglobin Level ◽

The Body ◽

Control Group ◽

Fetal Organ ◽

And Control

The needed of Iron Tablet in pregnancy was increase than mother who not pregnant. That cause of high metabolism at the pregnancy for formed of fetal organ and energy. One of effort for prevent anemia in mother pregnant with giving the Iron tablet and vitamin c. The reason of this research in 4 June – 11 July 2014 is for compare the effect of iron tablet suplementation with and without vitamin C toward Hemoglobin level in mother pregnant With Gestational Age Of 16-32 Weeks In Desa Keniten Kecamatan Mojo Kabupaten Kediri. This research method using comparative analytical. Research design type of Quasy Eksperiment that have treatment group and control group. Treatment group will giving by Iron tablet and 100 mg vitamin C, and control group just giving by iron tablet during 21 days. Population in this research are all of mother pregnant with Gestational Age Of 16-32 Weeks with Sampling technique is cluster random sampling is 29 mother pregnant. Comparison analysis of iron tablet suplementation effect with and without vitamin C toward Hemoglobin level in mother pregnant With Gestational Age Of 16-32 Weeks, data analysis using Mann Whitney U-test and the calculated U value (44,5) less than U-table (51). So there was difference of iron tablet suplementation effect with and without vitamin C toward Hemoglobin level in mother pregnant With Gestational Age Of 16-32 Weeks Therefore, the addition of vitamin C on iron intake is needed to increase the uptake of iron tablets. When the amount of iron uptake increases, the reserves of iron in the body will also increase, so as to prevent anemia in pregnant women; Keywords : Iron Tablet (Fe), Vitamin C, Hemoglobin level, Mother Pregnant

Download Full-text