Supraregional Centers Research Articles

Evaluation of Prehospital Undertriage in Relation to Trauma Team Activation-Results from a Prospective Study in 12 Level one German Trauma Centers.

Background/Objective: This prospective, multicenter observational cohort study was carried out in 12 trauma centers in Germany and Switzerland. Its purpose was to evaluate the rate of undertriage, as well as potential consequences, and relate these with different Trauma Team Activation Protocols (TTA-Protocols), as this has not been done before in Germany. Methods: Each trauma center collected the data during a three-month period between December 2019 and February 2021. All 12 participating hospitals are certified as supra-regional trauma centers. Here, we report a subgroup analysis of undertriaged patients. Those included in the study were all consecutive adult patients (age ≥ 18 years) with acute trauma admitted to the emergency department of one of the participating hospitals by the prehospital emergency medical service (EMS) within 6 h after trauma. The data contained information on age, sex, trauma mechanism, pre- and in-hospital physiology, emergency interventions, emergency surgical interventions, intensive care unit (ICU) stay, and death within 48 h. Trauma team activation (TTA) was initiated by the emergency medical services. This should follow the national guidelines for severe trauma using established field triage criteria. We used various denominators, such as ISS, and criteria for the appropriateness of TTA to evaluate the undertriage in four groups. Results: This study included a total of 3754 patients. The average injury severity score was 5.1 points, and 7.0% of cases (n = 261) presented with an injury severity score (ISS) of 16+. TTA was initiated for a total of 974 (26%) patients. In group 1, we evaluated how successful the actual practice in the EMS was in identifying patients with ISS 16+. The undertriage rate was 15.3%, but mortality was lower in the undertriage cohort compared to those with a TTA (5% vs. 10%). In group 2, we evaluated the actual practice of EMS in terms of identifying patients meeting the appropriateness of TTA criteria; this showed a higher undertriage rate of 35.9%, but as seen in group 1, the mortality was lower (5.9% vs. 3.3%). In group 3, we showed that, if the EMS were to strictly follow guideline criteria, the rate of undertriage would be even higher (26.2%) regarding ISS 16+. Using the appropriateness of TTA criteria to define the gold standard for TTA (group 4), 764 cases (20.4%) fulfilled at least one condition for retrospective definition of TTA requirement. Conclusions: Regarding ISS 16+, the rate of undertriage in actual practice was 15.3%, but those patients did not have a higher mortality.

Inpatient surgical treatment in mass casualty situations and disasters-Current treatment capacities depending on alarm status of the hospital and treatment concept

The functionality and treatment capacity of hospitals are decisive components to safeguard the in-hospital treatment of patients in crises and catastrophes. This is shown by the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic and the war in Ukraine. The aim of this study is the elicitation of treatment capacities of hospitals in the trauma network of the German Society for Trauma Surgery (DGU) assuming a damage situation with a multitude of trauma patients needing treatment. The 622 hospitals in the trauma network were surveyed to elicit the current treatment capacities depending on the principles and standards of treatment. For this purpose, a questionnaire for voluntary participation in the survey was placed online via the Academy of Trauma Surgery (AUC) of the DGU and an electronic platform (SurveyMonkey). The data presented in this article represent an extract of the total data focussed on the issues involved in the study. A total of 252 of the 622 hospitals certified in December 2022 (40%) participated in the survey and 250 datasets could be utilized. Local, regional and supraregional trauma centers were equally represented. Using a tactical abbreviated surgical control (TASC) focussed on survival, the treatment capacities in the individual triage categories could be increased with respect to the scenarios in question. It was also clear that the availability of teams skilled in the surgical treatment of body cavity injuries still represents a challenge. The results of the survey demonstrate the extent to which treatment capacities for the care of injured and wounded patients are currently available in the hospitals of the DGU trauma network and to what extent they can be increased. In this way, due the dynamics a mass casualty incident can initially lead locally and temporarily to a decompensated crisis management. The aim of all efforts and preparations must therefore be to durably strengthen hospitals so that this can be avoided as reliably as possible and to include these considerations in the hospital structural reform.

A Multicenter Study Validates the WHO 2022 Classification for Conjunctival Melanocytic Intraepithelial Lesions With Clinical and Prognostic Relevance

Several nomenclature and grading systems have been proposed for conjunctival melanocytic intraepithelial lesions (C-MIL). The fourth “WHO Classification of Eye Tumors” (WHO-EYE04) proposed a C-MIL classification, capturing the progression of noninvasive neoplastic melanocytes from low- to high-grade lesions, onto melanoma in situ (MIS), and then to invasive melanoma. This proposal was revised to the WHO-EYE05 C-MIL system, which simplified the high-grade C-MIL, whereby MIS was subsumed into high-grade C-MIL. Our aim was to validate the WHO-EYE05 C-MIL system using digitized images of C-MIL, stained with hematoxylin and eosin and immunohistochemistry. However, C-MIL cases were retrieved from 3 supraregional ocular pathology centers. Adequate conjunctival biopsies were stained with hematoxylin and eosin, Melan-A, SOX10, and PReferentially expressed Antigen in Melanoma. Digitized slides were uploaded on the SmartZoom platform and independently scored by 4 ocular pathologists to obtain a consensus score, before circulating to 14 expert eye pathologists for independent scoring. In total, 105 cases from 97 patients were evaluated. The initial consensus diagnoses using the WHO-EYE04 C-MIL system were as follows: 28 benign conjunctival melanoses, 13 low-grade C-MIL, 37 high-grade C-MIL, and 27 conjunctival MIS. Using this system resulted in 93% of the pathologists showing only fair-to-moderate agreement (kappa statistic) with the consensus score. The WHO-EYE05 C-MIL system (with high-grade C-MIL and MIS combined) improved consistency between pathologists, with the greatest level of agreement being seen with benign melanosis (74.5%) and high-grade C-MIL (85.4%). Lowest agreements remained between pathologists for low-grade C-MIL (38.7%). Regarding WHO-EYE05 C-MIL scoring and clinical outcomes, local recurrences of noninvasive lesions developed in 8% and 34% of the low- and high-grade cases. Invasive melanoma only occurred in 47% of the cases that were assessed as high-grade C-MIL. This extensive international collaborative study is the first to undertake a comprehensive review of the WHO-EYE05 C-MIL scoring system, which showed good interobserver agreement and reproducibility.

Ovruch slate spindle whorls in the Czech Lands

The article discusses the state of knowledge and the significance of a special group of early medieval material culture artefacts – namely, spindle whorls made of Ovruch pyrophyllite slate originating from the territory of present-day Ukraine. Thousands of these artefacts, interesting not only for their specific, usually reddish color, but also for their professional standardized design, were made between the 10th and 13th c. Their occurrence in the Czech lands is very limited, however: only 13 specimens are presently known. In Bohemia, they have been discovered only in Prague, which was their target destination. In Moravia and Czech Silesia, they are known from five sites: with a single exception (a cemetery), they are important supra-regional and local fortified centers. Non-destructive analyses carried out have shown that all detected spindle whorls can be considered originals. An analysis of the archaeological contexts showed that the earliest occurrence of these imports can be dated as far back as the second half of the 10th century. However, most of them probably belong to the 11th century, and some, exceptionally, even to the 12th century. Given their low number, we assume that this most probably was not a regular item in long-distance trade.

Requirements for trauma rehabilitation centers : Post-acute rehabilitation (phaseC) after severe trauma injury

Severely injured patients need aqualified and seamless rehabilitation after the end of the acute treatment. This post-acute rehabilitation (phaseC) places high demands on the rehabilitation facility in terms of personnel, material, organizational and spatial requirements.The working group on trauma rehabilitation of the German Society for Orthopedics and Traumatology e. V. (DGOU) and other experts have agreed on requirements for post-acute phaseC rehabilitation for seriously injured people. These concern both the personnel and material requirements for ahighly specialized orthopedic trauma surgery trauma rehabilitation as well as the demands on processes, organization and quality assurance.Aseamless transition to the follow-up and further treatment of seriously injured people in the TraumaNetzwerk DGU® is ensured through ahigh level of qualification and the corresponding infrastructure of supraregional trauma rehabilitation centers. This also places new demands on the TraumaZentren DGU®. Only if these are met can the treatment and rehabilitation of seriously injured people be optimized.

Infrastructure, logistics and clinical practice management of acute trauma hemorrhage and coagulopathy: a survey across German trauma centers

PurposeEarly detection and management of acute trauma hemorrhage and coagulopathy have been associated with improved outcomes, but local infrastructure, logistics and clinical strategies may differ.MethodsTo assess local differences in infrastructure, logistics and clinical management of acute trauma hemorrhage and coagulopathy we have conducted a web-based survey amongst clinicians working in DGU®-certified supraregional, regional and local trauma centers.Results137/1875 respondents completed the questionnaire yielding a response rate of 7.3%. The majority specified to work as head of department or senior consultant (95%) in trauma/orthopedic surgery (80%) of supraregional (38%), regional (34%) or local (27%) trauma centers. Conventional coagulation assays are most frequently used to monitor bleeding trauma patients. Only half of the respondents (53%) rely on extended coagulation tests, e.g. viscoelastic hemostatic assays. Tests to assess preinjury use of direct oral anticoagulants and platelet inhibitors are still not widely available and vary according to level of care. Conventional blood products are widely available but there remain differences between trauma centers of different level of care to access other hemostatic therapies, e.g. coagulation factor concentrates. Trauma centers of higher level of care are more likely to implement treatment protocols.ConclusionThis survey confirms still existing differences in infrastructure, logistics and clinical practice management for the detection of acute trauma hemorrhage and coagulopathy amongst DGU®-certified supraregional, regional and local trauma centers. Further work is recommended to locally implement diagnostics, therapies and treatment algorithms compliant to current guidelines to ensure the best possible outcomes in bleeding trauma patients.

Volume outcome relationship in penile cancer: a systematic review.

Penile cancer is a rare disease with significant morbidity. Because of the low volume of cases, it has been suggested that its treatment should be centralized in order to improve outcomes through better management of both the primary tumor and distant disease. We reviewed and summarized the most relevant recent publications regarding centralization of penile cancer management. Management of penile cancer in academic and supra-regional centers was associated with better survival outcomes. Moreover, reports from population-based studies showed more adherence to guidelines recommendations in academic centers with higher utilization of organ sparing treatments and invasive inguinal lymph node staging. The optimal management of penile cancer remains a major therapeutic challenge. Patients with invasive tumors are less adequately managed in lower volume nonspecialized centers. The data convincingly support efforts to centralize penile cancer care and to promote the development of centers of expertise in order to achieve the best possible outcomes for each patient.

Impact of Regional Organ Sharing and Allocation in the UK Northern Liver Alliance on Waiting Time to Liver Transplantation and Waitlist Survival.

In the United Kingdom, liver transplantation (LT) is undertaken in 7 supraregional centers. Until March 2018, liver grafts were offered to a center and allocated to a patient on their elective waiting list (WL) based on unit prioritization. Patients in Newcastle, Leeds, and Edinburgh with a United Kingdom Model for End-Stage Liver Disease (UKELD) score ≥62 were registered on a common WL and prioritized for deceased-donor liver allocation. This was known as the Northern Liver Alliance (NLA) "top-band scheme." Organs were shared between the 3 centers, with a "payback" scheme ensuring no patient in any center was disadvantaged. We investigated whether the NLA had improved WL survival and waiting time (WT) to transplantation. Data for this study were obtained from the UK Transplant Registry maintained by National Health Service Blood and Transplant. This study was based on adult patients registered for first elective liver transplant between April 2013 and December 2016. Non-NLA centers were controls. The Kaplan-Meier method was used to estimate WL survival and median WT to transplant, with the log-rank test used to make comparisons; a Bonferroni correction was applied post hoc to determine pairwise differences. WT was significantly lower at NLA centers compared with non-NLA centers for top-band patients (23 versus 99 days, P < 0.001). However, WL survival was not significantly different for top-band patients (P > 0.999) comparing NLA with non-NLA centers. WL survival for nontop-band patients was no different (P > 0.999) comparing NLA with non-NLA centers. The NLA achieved its aim, providing earlier transplantation to patients with the greatest need. Nontop-band patients did not experience inferior survival.

A Prospective Analysis of Complications of Intracranial Tumor Surgery.

Aims There is a recent trend toward delivering neurosurgical care in large supraregional centers with intradepartmental subspecialization. We report a 14-year prospective audit of a single surgeon's experience of intracranial tumor surgery with an emphasis on complications. Methods A total of 616 procedures were performed on 596 patients of which 321 were male and 275 were female (age range: 1-84 years). Tumors were categorized as glioma, meningioma, metastasis, and other. Complications were recorded as infection, intracranial hematoma, neurologic deterioration, and death. Results Of the 305 patients who underwent glioma surgery, 4 (1.3%) developed a hematoma, 4 (1.3%) had neurologic deterioration, 5 (1.6%) died within 30 days of surgery, and 1 (0.33%) had an infection. Of the 120 patients who underwent surgery for meningioma, 8 (6.6%) developed an infection, 1 (0.83%) developed a hematoma, and 7 (5.8%) had neurologic deterioration. Of the 59 patients who underwent surgery for brain metastasis, 1 (1.7%) had neurologic deterioration. Of the remaining patients, 4 (3.0%) developed infection and 6 (4.5%) had neurologic deterioration. Conclusions The overall complication rate was infection, 2.1%; hematoma, 0.8%; neurologic deterioration, 2.9%; and death, 0.8%. These results compare favorably with published series.

Long-term outcomes in thoracoabdominal aortic aneurysm repair for chronic type B dissection.

Open repair for chronic aortic dissection remains a challenging surgical option. Different centers report diverse experiences and outcomes pertaining to thoracoabdominal aortic aneurysm repair (TAAAR) for chronic type B dissection. We highlight our center's experience and results on a background of published literature and current evidence. We reviewed 214 open TAAAR performed between October 1998 and February 2014. Of these, chronic type B dissection was present in 62 (29.0%) patients. We reviewed these patients in terms of demographics, operative characteristics and outcomes. Thirteen (21.0%) patients had surgery on the descending thoracic aorta [Category A =2 (3.2%), B =0 (0%), C =11 (17.7%)] and 49 (79.0%) in the thoracoabdominal thoracic aorta [Crawford extent I =5 (8.1%), extent II =39 (62.9%), extent III =4 (6.5%), extent IV =1 (1.6%)]. Left heart bypass was used in 12 (19.4%) patients. The composite in-hospital endpoint, adverse outcome-defined as operative death, renal failure necessitating dialysis at discharge, stroke, or permanent paraplegia or paraparesis-occurred after 28 (45.2%) procedures. There were 14 (22.6%) operative deaths. In-hospital mortality was seven (16.3%) out of 43 elective patients, and increased to seven (36.8%) of the 19 non-elective ones. Permanent paraplegia or paraparesis occurred after two (3.2%) cases, stroke occurred after seven (11.3%) and renal failure requiring dialysis occurred after 16 (25.8%). Mean follow-up time was 3.2 years and actuarial 5-year mortality was 27.4% [nine (14.5%) elective and eight (12.9%) non-elective patients]. TAAAR in chronic type B dissection carries a substantial risk of early adverse outcomes. The results could be well alleviated with cases directed towards specialized regional and supra-regional centers. Although the endovascular approaches offer relatively low mortality and morbidity, there is a lack of long-term data and guidelines on their use. There is a need for a multidisciplinary international registry on the management of thoracoabdominal aortic aneurysms and dissection. This would provide a degree of guidance on relevant clinical and surgical judgments and outcomes.

Implementation of a nationwide trauma network for the care of severely injured patients.

Regional differences in the care of severely injured patients remain problematic in industrial countries. In 2006, the German Society for Trauma Surgery initiated the foundation of regional networks between trauma centers in a TraumaNetwork (TNW). The TNW consisted of five major elements as follows: (a) a whitebook on the treatment of severely injured patients; (b) evidence-based guidelines (S3); (c) local audits; (d) contracts of interhospital cooperation among all participating hospitals; and (e) TraumaRegister documentation. TNW hospitals are classified according to local audit results as supraregional (STC), regional (RTC), or local (LTC) trauma centers by criteria concerning staff, equipment, admission capacity, and responsibility. Five hundred four German trauma centers (TCs) were certified by the end of December 2012. By then, 37 regional TNWs, with a mean of 13.6 TCs, were established, covering approximately 80% of the country's territory. Of the hospitals, 92 were acknowledged as STCs, 210 as RTCs, and 202 as LTCs.In 2012, 19,124 patients were documented by the certified TCs. Fifty-seven percent of the patients were treated in STCs, 34% in RTCs, and 9% in LTCs. The mean (SD) Injury Severity Score (ISS) was highest in STCs (21 [13]), compared with 18 (12) in RTCs and 16 (10) in LTCs. There were differences in expected mortality (based on Revised Injury Severity Classification) according to the differences in the severity of trauma among the different categories, but in all types, the expected mortality was significantly higher than the observed mortality (differences in STCs, 1.8%; RTCs, 1.4%; LTCs, 2.0%). According to our findings, it is possible to successfully structure and standardize the care of severely injured patients in a nationwide trauma system. Better outcomes than expected were observed in all categories of TNW hospitals. Epidemiologic study, level III. Therapeutic/care management study, level IV.

Planned vaginal breech delivery: current status and the need to reconsider

Vaginal delivery of a breech baby is a necessary obstetrical skill since approximately 4% of babies at term are in breech presentation. Yet, on most delivery wards, the expertise required to deliver breech babies vaginally has virtually disappeared. Patients and obstetricians should be aware that there is no convincing evidence that cesarean section is better for the breech baby than assisted vaginal delivery, provided that certain strict criteria are met, and that cesarean section is associated with a higher risk of morbidity and mortality for the parturient than vaginal delivery. In addition, repeated cesarean sections carry additional substantial health risks for parturients. A trial of external cephalic version should be offered to all parturients who do not have contraindications for this procedure. Supraregional centers that specialize in breech delivery should be organized and basic simulator training for residents should be provided. In addition, a system of suprainstitutional standby teams of exp...

Absence of the Anterior Fontanelle Due to a Fontanellar Bone

Improved accessibility to supraregional centers in the United Kingdom has led to an increased referral of minor craniofacial anomalies. We have recognized a group of patients referred with absence of the anterior fontanelle and possible associated craniosynostosis. The aim of this study was to assess the group of patients in which the anterior fontanelle was entirely replaced by a single bone, examining associations, relationship to craniosynostosis, and prognostic implications.Eleven patients had fontanellar bones replacing the anterior fontanelle on computed tomographic imaging in the 3-year study period. Five were referred solely because of absence of the anterior fontanelle; and the remainder, because of concern of concomitant craniosynostosis. Five children had associated craniosynostosis (sagittal synostosis, 3; metopic synostosis, 1; and bicoronal synostosis, 1), 1 had acrocallosal syndrome, and 5 had no other craniofacial abnormalities. The patient group with craniosynostosis have been managed in line with the unit protocol and have good early postoperative results (mean postoperative follow-up, 9.4 mo). The 5 patients who had an anterior fontanellar bone as an isolated finding were observed and have developed normally with a mean follow-up of 2 years 1.4 months (range, 8 mo to 3 y 4 mo).Replacement of the anterior fontanelle with a fontanellar bone is an uncommon finding, often associated with craniosynostosis. Cases with craniosynostosis can be treated in line with unit protocols. Isolated anterior fontanellar bones can be managed conservatively without adverse impact on the child.

Traumanetzwerk vs. BG-Verfahren

Based on the so-called white paper on the structure for treating severely injured patients, a trauma network should be installed on the initiative of the German Society for Trauma Surgery. For decades, equipment and staff requirements for authorized surgical departments have been defined by the legal accident insurance industry. Regarding parameters for performance and equipment, department sizes have been defined for regional and supraregional trauma centers in a three-stage system. Both systems offer principle design options for an optimal quality-oriented supply situation adapted to specific needs.

The NCI-Ireland consortium: a unique international partnership in cancer care.

The Ireland-Northern Ireland-National Cancer Institute Cancer Consortium was launched in October of 1999, at a conference in Belfast, Northern Ireland, for the development of cancer programs in Ireland and Northern Ireland, where cancer is a significant cause of mortality and morbidity. Cancer services there have undergone major restructuring as a result of several government reports. Specifically, the National Strategy Document for Cancer proposed that cancer treatment services should be centered around primary care services, regional services, and a national coordinating structure where supra-regional centers would deliver specialist surgery, medical and radiation oncology, rehabilitation, and specialist palliative care. Therefore, this was an opportune time to bring the National Cancer Institute (NCI) on board in a determined effort to redevelop and significantly improve services and outcomes for cancer patients throughout the island. During the NCI All Ireland Cancer Consortium, initial major goals were established as follows: A) To share best available technology and enhance clinical research; B) conduct joint clinical research studies involving people from all jurisdictions; C) sponsor formal training exchanges for Irish and American scholars in cancer programs in partner institutions; D) implement the use of teleconferencing, telesynergy, and other information technology capabilities to facilitate education, and E) consolidate the Cancer Registries of Ireland and Northern Ireland and learn more about cancer incidence and trends on the entire island. In the past year, significant advances have been made in all these areas. Plans are already under way for the second NCI All Ireland Cancer Conference which will be held in late 2002 and feature speakers from Ireland, Northern Ireland, the U.S., and other areas. It will be open to all oncologists, researchers, nurses, students, and other health care professionals interested in learning and enhancing cancer care and research.

Care of adults with congenital heart disease--a challenge for the new millennium.

The care of complex congenital heart defect (CHD) patients should be continuous through life. Medium- and high-risk patients should be seen in special facilities for grown-up congenital heart (GUCH) patients, and followed for life. CHD in the adult is different than CHD in the child. Transitional programs should be available to prepare the adolescent patient to take charge of his/her own health. The patient should be transferred smoothly from pediatric to adult care. GUCH care should be regionally anchored in special facilities (groups or sometimes individuals) willing to make a commitment to their care. Ideally, pediatric and adult cardiologists will collaborate. GUCH care should be multidisciplinary wherever possible--and certainly in supraregional centers. Surgery, diagnostic catheterization, interventional cath procedures, EP management, and even MRI should be done in selected centers with high quality services for all cases other than the most simple lesions. Care should be available at all times. Surgeons who operate on children with similar conditions should perform the most GUCH surgery. GUCH surgery should be performed in centers with adequate institutional and individual surgeon's volumes. In determining which surgeons and units have adequate volumes, both pediatric and adult volumes should be combined.

Transition of care from pediatric to adult cardiologists – important aspects

A growing, heterogeneous group of children with congenital heart disease is surviving into adulthood due to advances in medicine. These patients including those with simple and complex congenital heart disease and operated on during childhood are facing long-term complications. Superspecialist care and expertise are required during their life to deal with their unique problems the most common being ventricular failure, arrhythmias, valve and conduit longevity. Teenagers and adolescents disappear from both medical and parental care because of the lack of transition programs. Transition of care from pediatric to adult cardiologists must be organized in each country and must reflect regional history, regional politics and realities. Transition of care requires goodwill from parents, adolescents, pediatric and adult cardiologists. Transition clinics being held jointly by pediatric and adult cardiologists between the age of 16 and 18 years are essential to encourage the adolescents to take charge of their own life and health issues. Adequate information about their heart defect, their operations and their residual lesions may help them understand the implications for the future and improve their compliance. A transition program must include counseling on education, career, endocarditis prophylaxis, insurance and lifestyle issues such as sexuality and reproduction (including anticonception, pregnancy), cardiovascular risk factors and sports activities. Medical reports including operative reports and heart catheterization reports must be transferred to the adult cardiologists. In Switzerland, care of adults with congenital heart disease is based on three levels: 1) primary caregivers including general practiioners, internists and community cardiologists; 2) cardiologists with special commitment and expertise to patients with congenital heart disease who organize regional outpatient clinics; 3) supraregional referral centers with cardiologists trained in pediatric and adult congenital heart disease and experienced in the special needs, problems and management of this unique population. A close collaboration between pediatric and adult cardiologists participating jointly in the care of congenital heart disease patients is very important. An interdisciplinary team offers all non-invasive and invasive facilities for diagnostic and therapeutic procedures in a supraregional referral center. A close collaboration among all physicians is crucial for optimal care and management. Integration of adolescents with congenital heart disease into an adult medical system improves both compliance and quality of care and supports the patient's esteem because many medical aspects and lifestyle issues are completely different from those during childhood.

The emerging adult population with congenital heart disease.

The successes in managing infants and children with congenital heart disease have led to an emerging population of adult patients. As we enter this new century, the majority of patients with congenital heart disease will be adults, not children. It is important to maintain our commitment for continuing care to the emerging adult population. Psycho-social issues, including employment and pregnancy counseling, are required as well as the ongoing need for medical and occasionally surgical intervention. The health care system needs to develop supra-regional tertiary referral centers for care of these patients and provide information sharing and support for community-based physicians interested in the welfare of the adult with congenital heart disease. Copyright 2000 by W.B. Saunders Company

The NCI All Ireland Cancer Conference

The NCI All Ireland Cancer Conference