Hospital Treatment Times Research Articles

Improving the management of hospital waiting lists by using nudges in letters: A Randomised controlled trial

ObjectiveA commonly adopted intervention to help to reduce wait times for hospital treatment is administrative validation, where administrators write to patients to check if a procedure is still required. The did not return (DNR) rate to validation letters is substantial. We tested whether the DNR rate was reduced by introducing nudges to validation letters. MethodsParticipants from eight public hospitals (N = 2855; in 2017) in Ireland were randomized to receive an existing (control group) or a redesigned validation letter including nudges (intervention group). ResultsParticipants in the intervention group were less likely not to return it than those in the control group, OR = .756, SE = .069, p = .002. Control and intervention group DNR rates were 23.97% and 19.24%. This is equivalent to 1 in 5 non-responders changing their behaviour because of the redesigned letter. ConclusionsThe redesigned letter increased patient compliance with the validation process. The redesign has subsequently been adopted by public hospitals in Ireland.

PS-C24-11: CLINICAL COURSE OF ACUTE DECOMPENSATED HEART FAILURE IN PATIENTS WITH RENAL DYSFUNCTION

The aim of the work: To determine the influence of the presence of impaired renal function on the clinical course of the disease of acute decompensated heart failure. Materials and methods: The prospective study involved 72 patients with acute decompensated heart failure aged 48 to 82 years (mean age 68.4 ± 2.1), including 53 (73.6%) men, who were successively hospitalized in the cardiology department of the Oleksandrivska Clinical Hospital in Kyiv, Ukraine. Patients were divided into two groups depending on GFR at hospitalization: < 60 ml/h/1.73m2, i.e. significantly reduced, and < 60 ml/h/1.73m2, i.e. mildly to moderately decreased. The results: In the group with reduced GFR, patients were significantly older in age (63.7 ± 2.83 vs. 56.4 ± 2.48, p < 0.01) and differed in a higher frequency of hypertension (84.7% vs. 55.6%, p < 0.01), diabetes mellitus (30.6% vs. 15.3%, p < 0.05), a decrease in LVEF < 45% (88.9% vs. 69.4%, p < 0.01). The average time of hospital treatment was 14.7 ± 0.9 days in the GFR < 60 group, and 11.6 ± 0.5 days in the GFR < 60 ml/h/1.73m2 group, p < 0.01. A greater severity of HF according to NYHA classes with a predominance of IV FC in patients of this group was associated with a greater severity of clinical manifestations of congestion - shortness of breath according to the Borg scale, congestion index (all p < 0.05), as well as an increase in E/E‘ by 22.7% and NT-proBNP - by 24.2% (p < 0.01). Conclusions: In patients with acute decompensated heart failure, renal dysfunction is observed in 62,5% of cases and is associated with a more difficult clinical course of the inpatient treatment period, a higher frequency of arterial hypertension, more severe signs of congestion and the need for more aggressive decongestive treatment. An additional negative contribution is the development of acute kidney injury during the first 48 hours in a significant part of patients.

Errors and complications in the treatment of patients with primary tumors of the lower limb long bones by the Ilizarov method

Based on the analysis of the treatment results of 133 patients with primary tumors of the lower limb long tubular bones, we describe the errors and complications of the Ilizarov method. We identified and analyzed the main groups of errors (organizational, tactical, and technical) and studied the treatment complications associated with them. These complications are not accompanied by significant anatomical and functional disorders, in the vast majority are treated by conservative measures and do not lead to the necessity to stop osteosynthesis. Systematization of errors and related complications determines a set of therapeutic and preventive measures for their prevention, while providing a more effective and high-quality rehabilitation of patients, reducing the time of hospital treatment of patients with tumor pathology of the long tubular bones.

ST-elevation myocardial infarction in a migrant population: a registry-based study of patient treatment and outcomes.

Internationally, a growing number of studies has identified race-related disparities in the presentation, treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI). With a large migrant population, Australia presents a unique microcosm in which to study the impact of migrant status and ethnicity in STEMI patients. To investigate if first-generation migrants differed in presentation, treatment or outcomes following STEMI compared with the Australian-born population. We conducted a retrospective observational study using data from a clinician-initiated registry. The study involved 2154 patients who presented to 12 hospitals between 2004 and 2012. Our main outcome measures included time to reperfusion, 30-day mortality and complications. Migrants (n = 1035, 48.8%) were more likely to be older (61 vs 58 years, P < 0.001), diabetic (29.3 vs 21.5%, P < 0.001) and have a prolonged symptom to door time (102 vs 91 min, P = 0.04). Despite lower rates of previous known ischaemic heart disease (22.5 vs 26.6%, P = 0.03), migrants had more diffuse disease (triple vessel or left main (3VD/LM): 29.8 vs 22.0%, P < 0.001) and higher troponin values (3.77 vs 3.22 μg/L, P = 0.01). We found no significant differences in hospital treatment times, intervention types or rates. Multivariate regression identified age, diabetes, female gender and multi-vessel disease as predictors of complications and death at 30 days. Migrants had longer pre-hospital delays and exhibited different cardiovascular risk profiles than Australian-born patients but received comparable treatment in the acute hospital setting. Higher rates of diabetes and multi-vessel coronary artery disease were seen among migrant patients, indicating a relatively higher risk population.

National prospective observational study of inpatient management of adults with epistaxis - a National Trainee Research Collaborative delivered investigation.

There is a paucity of high-quality evidence relating to the management of epistaxis severe enough to require admission to a hospital. Previous studies of interventions for epistaxis have suffered from small sample sizes. They lacked the power to allow analysis of the effect of an intervention on epistaxis control that is independent of the condition severity or additional interventions given. To determine the effect of specialist treatments on the successful management of severe epistaxis METHODOLOGY: Secondary analysis of data collected from a national multi-centre audit of patients with epistaxis over 30 days in 2016. Data were entered prospectively, and patients were followed up for 30 days following hospital discharge. 1402 adults admitted for inpatient management of epistaxis were identified in 113 participating UK hospitals, with data entered prospectively during the 30-day audit window. Exposure variables assessed included treatment instigated at first ENT review, intervention strategy during hospitalization, disease factors (e.g. severity), patient risk factors (e.g. co-morbidities, medications) and treatment factors (grade of doctor, therapies initiated during hospital stay). Main Outcomes include treatment time (time from first ENT review to time haemostasis was achieved and patient was safe for hospital discharge) and 30-day hospital readmission rate. 834 patients had sufficient data for inclusion. Patients who did not receive nasal cautery at first specialist review had a treatment time greater than double the time of those who were cauterised: Adjusted ratio (aR) 2.5 (95% CI 1.7-3.3), after controlling for age, bleeding severity, and whether they received a nasal pack or not. Only 30% of patients received management that complied with new national guidance, but those that did were 87% more likely to be achieve haemostasis before those that did not, even after controlling for bleeding severity. Type of treatment, whether initial intervention or management strategy, did not affect 30-day re-attendance. Analysis of national audit data suggest that cautery at first specialist review, and management according to national guidance can reduce hospital treatment times without compromising 30-day re-attendance. Future work should investigate why early nasal cautery is infrequently used, and how service delivery can be optimised to allow widespread implementation of evidence-based management for epistaxis.

The implementation of laser biostimulation at the early treatment stage of facial nerve palsy in children

Introduction: Peripheral-type facial nerve palsy (FNP) is called "Bell's paralysis". This is the most common type of damage to the facial nerve among children. Treatment includes the use of various types of pharmacologically assisted physical treatments. Study aim: The aim of the study is to evaluate the effectiveness of laser biostimulation in the treatment of peripheral FNP as well as the speed and sequence at which the disease symptoms subside. In addition, the relationship between the progress in physiotherapy and the patient's age were determined. Material and methods: The study included 50 patients (27 girls and 23 boys) aged 6 to 18 with FNP symptoms. Left-sided paralysis was noted in 22 of them, and right-sided in 28. All of the subjects included in the study were divided into two equal groups. In group A, treat-ment with the use of magnetic fields and electrostimulation was applied, while in group B, laser biostimulation was additionally applied. The speed and sequence of regression of symp-toms and the recovery of muscular strength were assessed. Results: In group A, in 17 of the treated children, symptoms subsided after 3 weeks. In group B, symptom relief occurred in 18 of them after 2 weeks. Due to one of the symptoms main-taining, although the symptom was not intense, 8 patients from group B continued ambulatory treatment, while 14 continued from group A. Conclusions: The early application of laser biostimulation in FNP patients leads to the rapid regression of symptoms and shortens the time of hospital treatment. Not fully shutting the eye and Bell’s symptoms were the quickest to subside. The age of the child with FNP does not affect the duration of treatment.

Space, place and (waiting) time: reflections on health policy and politics.

Health systems have repeatedly addressed concerns about efficiency and equity by employing trans-national comparisons to draw out the strengths and weaknesses of specific policy initiatives. This paper demonstrates the potential for explicit historical analysis of waiting times for hospital treatment to add value to spatial comparative methodologies. Waiting times and the size of the lists of waiting patients have become key operational indicators. In the United Kingdom, as National Health Service (NHS) financial pressures intensified from the 1970s, waiting times have become a topic for regular public and political debate. Various explanations for waiting times include the following: hospital consultants manipulate NHS waiting lists to maintain their private practice; there is under-investment in the NHS; and available (and adequate) resources are being used inefficiently. Other countries have also experienced ongoing tensions between the public and private delivery of universal health care in which national and trans-national comparisons of waiting times have been regularly used. The paper discusses the development of key UK policies, and provides a limited Canadian comparative perspective, to explore wider issues, including whether 'waiting crises' were consciously used by policymakers, especially those brought into government to implement new economic and managerial strategies, to diminish the autonomy and authority of the medical professional in the hospital environment.

Fast-Track Surgery principle simplementation in the minimally invasive surgery depatment state directorate for affairs, state research institution "Research and Practical Centre of Preventive and Clinical Medicine"

Modern life poses new challenges in medicine. Patients, who are going into surgery, want to be treated efficiently, safely, and quickly return to the normal life rhythm. The present level of medical progress allows us to do this. All these requirements are met by “Fast-Track Surgery” concept. This surgical treatment principle may be used in most surgical fields.«Fast-Track Surgery» includes pre-, intra- and post-operative periods. It has changed the generally accepted principles of patient preparation for surgery (excludes long period of fasting, bowel preparation, mandatory premedication), established new requirements for the surgical methods (laparo- and endoscopic techniques) and anesthetic management (the rapid post-anesthesia recovery for patient is required). In addition, early patient activation and early enteral nutrition are common standards of the «Fast-Track Surgery» nowadays.Minimally Invasive Surgery Center, based on the «Fast-Track Surgery» principles, was opened in the Research and Practical Center of Preventive and Clinical Medicine in 2007. Its structure includes a surgical hospital (36 beds), an operating unit (7 operating tables) and an intensive care unit (6 beds). More than 20 thousand patients received their surgery (16 surgical areas) in the Minimally Invasive Surgery Center since 2007. After the «Fast-Track Surgery» principles have been implementedin to the clinic routine patient’s comfort has inc reased and the time of hospital treatm ent has significantly reduced. Today, the average length of a hospital stay for in-patients is 1.9 days.

Sick of waiting: Does waiting for elective treatment cause sickness absence?

Sickness absence represents a substantial cost in most of Western Europe, whether the insurance scheme is public or private. The objective of this study was to analyse whether waiting time for elective treatment in specialist health care is associated with the length of individual sickness absence in Norway. To estimate the association between waiting time and the duration of sick leave, we used data from the working population aged 18–67 years in 2010–2012. The files combined register data from The Norwegian Patient Registry with individual characteristics and sickness absence data from Statistics Norway, and was analysed using zero-truncated negative binomial regression. We found that about one in four employees who had one or more spells of sick leave in the period, was also waiting for consultation or treatment in specialist health care. Yet, the length of the waiting period had no substantial effect on the length of sickness absence (i.e., less than 0.1% reduction). Therefore, while measures to reduce waiting times for hospital treatment in many instances could be beneficial for the individual patient, such policies would probably not have any substantial impact on the national sickness absence rate.

Public reporting on quality, waiting times and patient experience in 11 high-income countries

This article maps current approaches to public reporting on waiting times, patient experience and aggregate measures of quality and safety in 11 high-income countries (Australia, Canada, England, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland and the United States). Using a questionnaire-based survey of key national informants, we found that the data most commonly made available to the public are on waiting times for hospital treatment, being reported for major hospitals in seven countries. Information on patient experience at hospital level is also made available in many countries, but it is not generally available in respect of primary care services. Only one of the 11 countries (England) publishes composite measures of overall quality and safety of care that allow the ranking of providers of hospital care. Similarly, the publication of information on outcomes of individual physicians remains rare. We conclude that public reporting of aggregate measures of quality and safety, as well as of outcomes of individual physicians, remain relatively uncommon. This is likely to be due to both unresolved methodological and ethical problems and concerns that public reporting may lead to unintended consequences.

Respiratory Disorders in Complicated Cervical Spine Injury

Objective. Evaluating the results of respiratory therapy in patients with complicated traumatic injury of the cervical spine. Materials and methods . A retrospective comparative analysis of the clinical course was carried out in 52 patients with complicated traumatic injury of the cervical spine: group A: complete spinal cord injury (ASIA A), 37 patients and group B: incomplete injury (ASIA B), 15 patients. The severity of patients' status on integral scales, parameters of the respiratory pattern and thoracopulmonary compliance, gas composition, and acidbase status of the blood were assessed. Data on patients who required prolonged mechanical ventilation, duration of mechanical ventilation, incidence of nosocomial pneumonia, duration of stay in the ICU, time of hospital treatment, and mortality were included in the analysis. Results. The average APACHE II and SOFA scores were higher in group A patients. The development of the acute respiratory failure required longterm mechanical ventilation (more than 48 hours) in 91.4% of group A patients and in 53.3% of group B patients. Ventilatorassociated pneumonia complicated the disease in 81.3% of group A patients and 62.5% of group B patients and was accompanied by sepsis in 25% and 12.5% of cases, respectively. Statistically significant deterioration of biomechanical properties and gas exchange function of the lungs was observed in patients complicated with septic pneumonia. Conclusion. Patients with complicated ASIA A and ASIA B cervical spine injuries demonstrate the presence of respiratory failure of neurogenic origin. In addition, the infectious bronchopulmonary complications aggravated respiratory failure in patients with ASIA A injury in 70.3% versus 33.3% in patients with ASIA B. Development of pulmonogenic sepsis led to deterioration of the biomechanical and gas exchange functions of the lungs and increased the likelihood of unfavorable outcome of the disease in 77.8% of cases. The high incidence of respiratory disorders in patients with complicated cervical spine injury requires timely decision on ventilatory support, especially in patients with complete spinal cord injury.

Prioritization and the elusive effect on welfare – A Norwegian health care reform revisited

The Faster Return to Work (FRW) scheme that Norwegian authorities implemented in 2007 is an example of a policy that builds on the human capital approach. The main idea behind the scheme is that long waiting times for hospital treatment lead to unnecessarily long periods of absence from work. To achieve a reduction in average sickness absence duration, the allocation of FRW funds and new treatment capacity is exclusively aimed at people on sick leave. Many countries have allocated funds to reduce waiting times for hospital treatment and research shows that more resources allocated to the hospital sector can reduce waiting times. Our results support this as the FRW scheme significantly reduces waiting times. However, on average the reduction in waiting times is not transformed into an equally large reduction in the sickness absence period. We find significant difference in the effects of FRW on length of sick leave between surgical and non-surgical patients though. The duration of sick leave for FRW patients undergoing surgical treatment is approximately 14 days shorter than for surgical patients on the regular waiting list. We find no significant effect of the scheme on length of sick leave for non-surgical patients. In sum, our welfare analysis indicates that prioritization of the kind that the FRW scheme represents is not as straightforward as one would expect. The FRW scheme costs more than it contributes in reduced productivity loss. We base our analyses on several different econometric methods using register data on approximately 13 500 individuals over the period 2007–2008.

Initial experience of a series of robotic-assisted laparoscopic adrenalectomy

ObjectivesWe present our initial experience using robotic-assisted laparoscopic adrenalectomy in the surgical treatment of adrenal masses. Material and methodsA total of 18 patients (11 women and 7 men) diagnosed of a functioning or non-functioning adrenal tumor mass were operated on in our facilities between October 2009 and October 2011. Surgical variables, intra-hospital recovery time, pathological findings and peri- and post-operatory findings were evaluated. ResultsMean age of the population intervened was 51.2 years (range 18–81), average ASA score 2.11 (range 1–4) and BMI 27.0 (range 18.8–36.1). Of the 18 patients, 11 were operated on the left side and 7 on the right. Mean surgery time was 150 (range 84–329) min and intra-operatory bleeding 121 (range 10–1500) ml, with a mean loss of hemoglobin and hematocrits of 2.11g/dl and 6.33%, respectively. Two patients were converted to conventional surgery. The factors influencing surgical conversion were: normal size (>10cm), tumor weight (>100g), active pheochromocytoma and left localization of the tumor. Seven functioning cortical adenomas, 6 metastatic adrenal tumors, 3 pheochromocytoma and 2 incidental tumors were excised. Mean tumor size was 5.39 (range 3–15) cm. Median hospital stay was 6 days (range 4–14). Five patients had peri-operatory complication. Of these, only one (5%) had major complications (Clavien III). Mean follow-up was 6 months (range 2–24). ConclusionsRobotic technology for laparoscopic adrenalectomies is a valid option for adrenal tumor treatment. In our experience with a relatively short learning curve, it makes it possible to reduce hospital treatment times and the intra- and post-operatory complications, without affecting the oncological and post-operatory functional results.

Will Delays in Treatment Jeopardize the Population Benefit From Extending the Time Window for Stroke Thrombolysis?

Pooled analyses show benefits of intravenous alteplase (recombinant tissue-type plasminogen activator) treatment for acute ischemic stroke up to 4.5 hours after onset despite marketing approval for up to 3 hours. However, the benefit from thrombolysis is critically time-dependent and if extending the time window reduces treatment urgency, this could reduce the population benefit from any extension. Based on 3830 UK patients registered between 2005 to 2010 in the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR), a Monte Carlo simulation was used to model recombinant tissue-type plasminogen activator treatment up to 4·5 hours from onset and assess the impact (numbers surviving with little or no disability) from changes in hospital treatment times associated with this extended time window. We observed a significant relation between time remaining to treat and time taken to treat in the UK SITS-ISTR data set after adjustment for censoring. Simulation showed that as this "deadline effect" increases, an extended treatment time window entails that an increasing number of patients are treated at a progressively lower absolute benefit to a point where the population benefit from extending the time window is entirely negated. Despite the benefit for individual patients treated up to 4.5 hours after onset, the population benefit may be reduced or lost altogether if extending the time window results in more patients being treated but at a lower absolute benefit. A universally applied reduction in hospital arrival to treatment times of 8 minutes would confer a population benefit as large as the time window extension.

Experiencia inicial con una serie de adrenalectomía laparoscópica asistida por robot

ObjectivesWe present our initial experience using robotic-assisted laparoscopic adrenalectomy in the surgical treatment of adrenal masses. Material and methodsA total of 18 patients (11 women and 7 men) diagnosed of a functioning or non-functioning adrenal tumor mass were operated on in our facilities between October 2009 and October 2011. Surgical variables, intra-hospital recovery time, pathological findings and peri- and post-operatory findings were evaluated. ResultsMean age of the population intervened was 51.2 years (range 18-81), average ASA score 2.11 (range 1-4) and BMI 27.0 (range 18.8-36.1). Of the 18 patients, 11 were operated on the left side and 7 on the right. Mean surgery time was 150 (range 84-329) min and intra-operatory bleeding 121 (range 10-1500) ml, with a mean loss of hemoglobin and hematocrits of 2.11g/dl and 6.33%, respectively. Two patients were converted to conventional surgery. The factors influencing surgical conversion were: normal size (>10cm), tumor weight (>100g.), active pheochromocytoma and left localization of the tumor. Seven functioning cortical adenomas, 6 metastatic adrenal tumors, 3 pheochromocytoma and 2 incidental tumors were excised. Mean tumor size was 5.39 (range 3-15) cm. Median hospital stay was 6 days (range 4-14). Five patients had peri-operatory complication. Of these, only one (5%) had major complications (Clavien III). Mean follow-up was 6 months (range 2-24). ConclusionsRobotic technology for laparoscopic adrenalectomies is a valid option for adrenal tumor treatment. In our experience with a relatively short learning curve, it makes it possible to reduce hospital treatment times and the intra- and post-operatory complications, without affecting the oncological and post-operatory functional results.

Rotary blood-supplied patches for the treatment of osteomyelitis of the bones of the foot and the distal third of the tibia

The results of 112 transpositions of blood receiving complexes tissue foot applied in the treatment of chronic posttraumatic osteomyelitis of the bones of the foot and the distal third of the shin. Positive results were obtained in 86,6% of patients with recovery to work in 81,5% of the patients. The authors argue that the proposed blood receiving complexes tissue foot in the treatment of chronic posttraumatic osteomyelitis of the bones of the foot and the distal third of the shin allow to depart from the practice of multistage operations, reduce the time of hospital treatment. The algorithm for help in the treatment of chronic posttraumatic osteomyelitis of the bones of the foot and the distal third of the shin.

A Simple Strategy Improves Prehospital Electrocardiogram Utilization and Hospital Treatment for Patients with Acute Coronary Syndrome (from the ST SMART Study)

Although the American Heart Association recommends a prehospital electrocardiogram (ECG) be recorded for all patients who access the emergency medical system with symptoms of acute coronary syndrome (ACS), widespread use of prehospital ECG has not been achieved in the United States. A 5-year prospective randomized clinical trial was conducted in a predominately rural county in northern California to test a simple strategy for acquiring and transmitting prehospital ECGs that involved minimal paramedic training and decision making. A 12-lead ECG was synthesized from 5 electrodes and continuous ST-segment monitoring was performed with ST-event ECGs automatically transmitted to the destination hospital emergency department. Patients randomized to the experimental group had their ECGs printed out in the emergency department with an audible voice alarm, whereas control patients had an ECG after hospital arrival, as was the standard of care in the county. The result was that nearly 3/4 (74%) of 4,219 patients with symptoms of ACS over the 4-year study enrollment period had a prehospital ECG. Mean time from 911 call to first ECG was 20 minutes in those with a prehospital ECG versus 79 minutes in those without a prehospital ECG (p <0.0001). Mean paramedic scene time in patients with a prehospital ECG was just 2 minutes longer than in those without a prehospital ECG (95% confidence interval 1.2 to 3.6, p <0.001). Patients with non-ST-elevation myocardial infarction or unstable angina pectoris had a faster time to first intravenous drug and there was a suggested trend for a faster door-to-balloon time and lower risk of mortality in patients with ST-elevation myocardial infarction. In conclusion, increased paramedic use of prehospital ECGs and decreased hospital treatment times for ACS are feasible with a simple approach tailored to characteristics of a local geographic region.

Reducing Waiting Times for Hospital Treatment: Lessons from the English NHS

In recent years, the English NHS has achieved substantial reductions in waiting times for hospital treatment. This paper considers first whether the data used by the Government provide an accurate description of changes in waiting times and identifies some of the limitations of the measures used. It then attempts to identify how reductions have been achieved. It argues that some features of central government policy have been important - such as the use of targets - others, such as the introduction of new private sector capacity have not. It also shows that changes at local level have been critical to achieving the recorded improvements, but the precise impact of these is hard to identify.

Clinical results of the application of perftoran for the treatment of odontogenous abcesses and phlegmons in the maxillofacial region

The study was carried out to ascertain the effects of perftoran in the treatment of facial and Dupuytren's phlegmons with simultaneous estimation of the general reaction in humans. Seventy-six patients with facial or Dupuytren's phlegmons were divided into 2 groups, one with mild and the other with a severe course of the inflammatory process. Each group was subdivided into 2 subgroups: one control group with "traditional" treatment and one study group where the traditional treatment was supplemented with perftoran. Perftoran was given to both study groups (1-3 ml/kg body weight, single intravenous injection) immediately after surgery plus further daily local wound treatment with perftoran until the end of exudation. The condition of the purulent wound and its reparative processes, the state of free-radical oxidation processes, antihypoxia and effects of perftoran were evaluated at various treatment stages (the moment of surgically opening the phlegmon, on the 1st, 3rd and 7th postoperative days). Perftoran considerably decreased the tissue hypoxia as well as the transaminase and creatinine levels in blood serum. Perftoran helped to decrease the intoxication indices, hypoxaemia by 10-15%, to speed local wound healing by 2-5 days and to shorten the time of hospital treatment by 3-6 days on average. The many positive effects of perftoran on the clinical course of the disease and on a series of homeostatic parameters allow us to recommend that this drug to be added for treating patients having odontogenous phlegmons in the maxillofacial region.

A Typology of Advance Statements in Mental Health Care

A Typology of Advance Statements in Mental Health Care