Interhospital transfers are essential to ensure access to appropriate levels of care, yet many transfers are potentially avoidable, leading to unnecessary resource use and patient burden. To determine the association between telemedicine and interhospital transfer rates among patients considered for an interhospital transfer. Five databases were searched from database inception to 20 January 2026. Studies including patients considered for transfer between hospitals, studies comparing telemedicine with usual care, and studies reporting interhospital transfers rates. Two independent reviewers extracted data and assessed risk of bias. The primary outcome was interhospital transfer rate; the secondary outcome was death. Grouping by patient population, clinical indication for transfer, setting, and intervention characteristic was done. Thirty-three studies representing 609 188 patients were included. Given substantial clinical and methodological heterogeneity, a structured narrative synthesis was done. Telemedicine was commonly associated with lower transfer rates in adult (13 of 17 adult only studies) and pediatric (4 of 5 studies) populations, across clinical indication for transfer (medical [9 of 14 studies] versus surgical [6 of 7 studies] versus acute care conditions [7 of 12 studies]), and rural (9 of 16 studies) and urban (9 of 10 studies) settings. Variation in the transfer rate changes was driven by differences in confounder adjustment, comparator definitions, and study design. Telemedicine was associated with lower or unchanged mortality in most studies that assessed mortality (15 of 17 studies). Included studies were mostly observational with risk for confounding, with high heterogeneity driven by variability in study populations, telemedicine models, comparator groups, clinical contexts, and methodological approaches. Telemedicine may support appropriate triage and reduce potentially avoidable interhospital transfers, with no adverse association on mortality, contributing to safe and efficient transfer decision making. None. (PROSPERO: CRD42023493486).
Home dialysis can offer persons with kidney failure a more individualized, flexible, and independent method of dialysis compared with in-center hemodialysis (ICHD), with similar survival outcomes. Home dialysis is also generally less expensive for payers. Despite its advantages, home dialysis remains significantly underused in the United States, particularly among patients with low socioeconomic status. This article addresses current disparities in access to dialysis by examining the history and politics of home dialysis from the 1960s to the present, drawing on hundreds of archival records from dialysis organizations, for-profit dialysis companies, patient advocacy networks, public media, and congressional hearings. The enactment of the Medicare End-Stage Renal Disease (ESRD) program in 1972 was a monumental victory not just for patients receiving dialysis but also for the growing dialysis industry. In the first 4 years of the program, the rate of home dialysis among ESRD patients decreased from 43% to 20% as patients increasingly dialyzed at for-profit centers. This decline was attributed to financial disincentives, a changing patient demographic, and increased availability of ICHD. By the mid-1970s, expenses for the ESRD program had grown so high that the government turned to home dialysis as a cost-saving measure. Low-income, marginalized patients soon found themselves at the center of a debate between dialysis companies, nonprofit dialysis organizations, and government officials over who was capable of home dialysis. These debates raised questions about the ethics of for-profit medicine, patient representation in policymaking, and the potential for discrimination in incentive models. Despite implementation of financial incentives for home dialysis in 1978 and 1983, home dialysis remained underused, pointing to greater socioeconomic barriers to home dialysis access and gaps in addressing patient needs.
Addition of glucagon-like peptide-1 receptor agonists (GLP-1RAs) to basal insulin can decrease insulin requirements, but whether it permits insulin discontinuation is unclear. To compare rates of insulin discontinuation among patients with type 2 diabetes (T2D) receiving basal insulin who initiated treatment with a GLP-1RA, sodium-glucose cotransporter-2 inhibitor (SGLT-2i), or dipeptidyl peptidase-4 inhibitor (DPP-4i) between 2020 and 2022. Target trial emulation. U.S. Veterans Health Administration electronic health record (EHR) data. Veterans with T2D receiving basal insulin. Insulin discontinuation, defined as the first gap in insulin prescription fills of 12 months or more over 3 years of follow-up. Among 8869 matched sets of GLP-1RA (76.6% semaglutide, 15.2% dulaglutide, 7.9% liraglutide, and 0.3% exenatide), SGLT-2i (99.7% empagliflozin), and DPP-4i (95.9% alogliptin) initiators, 63% were 65 years or older, 93% were male, 70% were White, and 48% had a hemoglobin A1c (HbA1c) level of 9% or more. Over 3 years of follow-up, 1480 (16.7%) GLP-1RA initiators compared with 1585 (17.9%) SGLT-2i initiators and 1517 (17.1%) DPP-4i initiators discontinued insulin therapy in the intention-to-treat analysis (risk ratio, 0.93 [95% CI, 0.86 to 1.01] and 0.98 [CI, 0.87 to 1.09] for the GLP-1RA arm compared with the SGLT-2i and DPP-4i arms, respectively). Results were not substantively different in a modified per protocol analysis. None of the subgroups showed a comparative advantage of GLP-1RAs with respect to insulin discontinuation over SGLT-2is or DPP-4is. Possible residual confounding; misclassification of exposure and outcome using EHRs may bias associations toward the null. Among veterans with T2D receiving basal insulin therapy, addition of GLP-1RA did not increase the chances of stopping insulin therapy compared with SGLT-2i or DPP-4i therapy. U.S. Department of Veterans Affairs.
Olorofim, a novel dihydroorotate dehydrogenase inhibitor, may be efficacious in patients with disseminated coccidioidomycosis (DCM) who lack alternative treatment options. To evaluate olorofim effectiveness and adverse events in patients with DCM. Single-group, open-label, phase 2b study. (ClinicalTrials.gov: NCT03583164). Ten U.S. sites. Forty-one patients with DCM and limited or no treatment options. Patients received olorofim alone or in combination with ongoing standard of care during an 84-day main treatment phase. Extended treatment was offered to patients. Mycoses Study Group-European Organization for Research and Treatment of Cancer (MSG-EORTC) criteria for global response based on subcategories of clinical, radiologic, and mycologic response were adjudicated by an independent data review committee (DRC) at days 42 and 84 (main treatment phase). Because the slow pace of serologic improvement in DCM limits global response to stable at best, this article focuses on patient clinical responses. Treatment-emergent adverse events (TEAEs) were compiled for both treatment phases. Forty-one patients with DCM were enrolled from May 2019 to August 2022. Thirty-nine (95.1%) did not have immunosuppression. Central nervous system disease was present in 30 (73.2%) patients, and 13 (43.3%) had a ventriculoperitoneal shunt with or without an Ommaya reservoir. Clinical success as adjudicated by the DRC occurred in 31 of 41 patients (75.6% [95% CI, 59.7% to 87.6%]) at day 42 and 30 of 41 patients (73.2% [CI, 57.1% to 85.8%]) at day 84. The main TEAE was hepatic biochemistry elevation in 9 of 41 patients (21.9%), which was managed by liver enzyme monitoring and dose reduction or pause in 8 patients (19.5%) and drug discontinuation in 1 patient (2.4%). This was a single-group, open-label trial, but a randomized controlled trial would be preferable. Olorofim showed effectiveness in patients with DCM with limited or no therapeutic options. F2G, Ltd.
Prevalence and incidence are fundamental metrics with numerous applications in epidemiology. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline lacks specific items for reporting studies of disease prevalence or incidence. To address this gap, the STROBE Enhanced Prevalence and Incidence Criteria (STROBE EPIC) extension was developed in accordance with established methods for reporting guideline development. The authors generated an initial list of reporting items, conducted a modified Delphi process, and convened a face-to-face consensus meeting to confirm the need for a STROBE extension and to generate an early version of the checklist. They conducted 2 further Delphi surveys, first extending from typhoid and other invasive salmonelloses to all infectious diseases, and then to noncommunicable diseases and injuries. Finally, experts piloted the checklist on relevant manuscripts to critically assess if it was clear, concise, complete, and free of errors. An executive group curated the checklist after every survey round. The STROBE EPIC checklist comprises 47 items in the domains of title (1 item), abstract (2 items), introduction (1 item), methods (25 items), results (6 items), discussion (7 items), and other information (5 items). STROBE EPIC items address reporting of study design, adjustment factors for underreporting and underdiagnosis, denominator population estimation, case ascertainment methods, factors producing artefactual changes to observed disease prevalence or incidence, limitations of incomplete surveillance coverage, generalizability of short-duration studies, and data availability. The authors anticipate that the STROBE EPIC extension will be used by researchers, authors, modelers, burden-of-disease researchers, peer reviewers, and journal editors to optimize the presentation of epidemiologic evidence to support diverse health policy decisions.
Insufficient sleep is associated with obesity. However, the causal effect on weight status of chronic, mildly insufficient sleep and its potential variability by gender and menopausal status remain unknown. To explore the effect of 6 weeks of sleep restriction (SR) of 1.5 hours per night on energy balance and body weight regulation. Pooled analysis of 2 randomized crossover trials. (ClinicalTrials.gov: NCT02960776 and NCT02835261). Outpatient intervention with inpatient and outpatient assessments. Adults (n = 95) aged 20 years or older at elevated cardiometabolic risk with habitual sleep of 7 or more hours per night. Six weeks of sustained adequate sleep (AS) and SR of 1.5 hours per night separated by a multiweek washout. Outcome measures included adiposity (assessed using magnetic resonance imaging), body weight, waist circumference, and energy balance behaviors and biomarkers. Sleep duration was reduced by 78.4 minutes (95% CI, -83.5 to -73.3 minutes) per night with SR versus AS. Body weight (0.45 kg [CI, 0.33 to 0.57 kg]), waist circumference (0.52 cm [CI, 0.25 to 0.79 cm]), and whole-body volume (0.56 L [CI, 0.19 to 0.93 L]) were increased with SR relative to AS. Leptin levels were elevated with SR versus AS (2.03 ng/mL [CI, 0.38 to 3.68 ng/mL]). Sedentary time was increased by 17.2 minutes (CI, 11.7 to 22.7 minutes) per day with SR versus AS. The intervention duration may have been too short to identify changes in body composition, power to evaluate individual differences was limited, and effect sizes were modest. Prolonged exposure to moderately short sleep may lead to weight gain, suggesting that weight management and cardiometabolic disease prevention programs should consider incorporating sleep strategies to promote AS. National Institutes of Health and American Heart Association.
Lithium has long been considered to reduce suicidal behaviour in patients with affective disorders, but evidence from large real-world populations remains limited. To estimate the effects of lithium initiation and continuation on suicide deaths and non-lethal suicidal behaviours among adults with bipolar disorder or major depressive disorder. We emulated two target trials using electronic health records and administrative claims from US veterans between January 2010 and December 2022. The first trial benchmarked results against the CSP-590 randomised trial by estimating the 1-year risk of suicide-related events (non-fatal suicide attempts, hospitalisations to prevent suicide or suicide deaths) among patients with a recent suicide attempt initiating lithium versus not initiating lithium. The second trial extended follow-up to 10 years to estimate risks of suicide deaths and non-lethal suicidal behaviours separately, including subgroup analyses by age and diagnosis. An additional analysis removed the requirement of a prior suicide attempt. In the benchmarking analysis, the 1-year risk ratio for suicide-related events comparing lithium initiation with no initiation was 1.06 (95% CI 1.01 to 1.12), consistent with findings from the CSP-590 trial. In the extended analysis, the 10-year per-protocol risk ratio for suicide death was 1.00 (95% CI 0.86 to 1.15) and for non-lethal suicidal behaviours was 0.96 (95% CI 0.90 to 1.02). Results were similar among individuals with and without a prior suicide attempt. When added to ongoing pharmacological treatment for patients with affective disorders, lithium may not substantially reduce suicide risk highlighting the need for additional suicide prevention strategies in this population. Limitations include lack of information on adherence, dosage or blood levels of lithium which may have obscured existing differences. Our findings suggest that adding lithium therapy to the ongoing treatment regimens of patients with affective disorders for the sole purpose of reducing suicide may not be well-tolerated or meaningfully reduce suicide risk.
State legislative initiatives that were started in 2023 to streamline the licensing of internationally trained physicians (ITPs) have garnered bipartisan interest and support across the country. The new approach, more broadly applicable than previous efforts, precludes a requirement for Accreditation Council for Graduate Medical Education-accredited graduate medical education conducted in the United States. The change is the most recent development in our nation's long and winding history of licensing international medical graduates (IMGs). At the turn of the 20th century, only about 100 IMGs presented to state medical boards each year for licensure. Medical graduates around the world who sought quality postgraduate training opportunities, including those from the United States, looked to Europe. Nativist sentiment and state and federal laws in the 1920s discouraged or prohibited immigration for many internationally educated or trained physicians. That changed substantially during and after World War II when a population surge, an increase in physician refugees, and, later in the 1960s, relaxed immigration laws combined with a robust expansion of hospitals to shift the medical regulatory landscape. The result was greater receptivity to IMGs, with concerns about prevailing credentialing models predicated on recognition by state medical boards of "approved" international medical schools. The establishment of the Educational Commission for Foreign Medical Graduates in the 1950s mirrored a broader shift toward evaluation of persons and their capabilities. Recent demographic pressures (for example, a growing and aging patient population and a maldistributed and insufficient physician workforce) are prompting a flurry of state legislative initiatives to improve access to care and welcome more IMGs, especially ITPs, in a trend that runs counter to growing federal restrictions on immigrants and international workers.
Forty percent of U.S. adults have obesity, a complex condition determined by genetics, behavior, environment, and other modifiable and nonmodifiable factors. Obesity is associated with certain comorbid conditions, including type 2 diabetes, high cholesterol, heart disease, and some cancer types, and may increase the severity of communicable illnesses, such as influenza. Treatments of obesity include behavioral modification, pharmacotherapy, and surgical procedures, but high cost and coverage restrictions are a substantial barrier for many patients. In this position paper, the American College of Physicians (ACP) offers recommendations on how policymakers can increase the affordability and accessibility of obesity treatment for adults and address modifiable factors that contribute to obesity, like diet and physical activity. ACP also includes recommendations on reducing stigma associated with obesity, improving understanding of obesity among physicians, increasing access to healthy food, and curbing the proliferation of unhealthy, highly processed fare. Population health strategies for addressing obesity are also discussed.
In 2025, the United States experienced its highest measles case count since 1992. In New Mexico, 100 confirmed measles cases (99 outbreak-related cases), including 1 death, occurred across 9 counties from February through September 2025. To estimate the societal economic burden of this outbreak while highlighting public health expenditures for vaccination-related activities that supported outbreak control and prevention of future outbreaks. Cost analysis from a societal perspective to estimate 3 types of costs: public health response costs, direct medical costs, and productivity losses. Nine counties in New Mexico during February to September 2025. 133 public health responders, 100 patients with confirmed measles, and 205 exposed contacts. Public health response activities, including vaccination campaigns, case management, and contact tracing. Costs were categorized as response costs (labor, materials, travel), direct medical costs (third-party), or productivity losses (illness, isolation, quarantine, caregiving). The overall societal cost was estimated at $5.4 million ($53 522 per case, or $1817 per contact). The largest component of the public health response to the outbreak (about $3.2 million) was costs from vaccination-related activities (about $2.1 million). Costs may be overestimated or underestimated due to incomplete reporting; insurance data were used rather than actual medical costs; certain direct medical costs were excluded; and assumptions were made for productivity losses. These estimates offer important insights for decision making by policymakers and public health stakeholders regarding budgets for and expansion of vaccination coverage during an outbreak and strengthening outbreak preparedness. This study also highlights the societal value of protecting communities from vaccine-preventable diseases like measles, which can be effectively prevented through high vaccination coverage. None.
Perioperative cardiovascular management involves the assessment and identification of risks in patients undergoing surgery, as well as development of a plan for mitigation of those risks during and after the procedure. It includes risk stratification, which provides guidance for preoperative testing and perioperative management in patients at high risk while avoiding overscreening in those at low risk. Specific guidance is informed by the patient's medical comorbid conditions, functional capacity, and type and urgency of planned surgery. In 2024, the American Heart Association, the American College of Cardiology, and other professional organizations published a comprehensive set of evidence-based recommendations for the evaluation and management of cardiovascular risk in adults undergoing noncardiac surgery. Its methodology included systematic literature review, multidisciplinary expert consensus, and peer review. Here, 2 experts in this field, a general internal medicine physician and a cardiologist, debate how to manage the case of an 80-year-old man with multiple cardiopulmonary conditions and other organ system comorbidities who is scheduled to undergo extensive skin cancer surgery. They discuss how to approach preoperative evaluation of such a patient with a focus on optimizing his status and monitoring for cardiac complications during and after the procedure.
Whether direct oral anticoagulants (DOACs) are a safe and effective alternative to warfarin in patients with atrial fibrillation and mitral stenosis (AF-MS) remains controversial. To evaluate the effectiveness and safety of DOACs versus warfarin in patients with AF-MS. Observational cohort study using target trial emulation. Population-wide insurance claims data in Taiwan. Patients diagnosed with AF-MS and prescribed either DOACs or warfarin between 1 January 2011 and 31 December 2021 were included in the study. DOACs or warfarin. Absolute risk differences (RDs) and risk ratios (RRs) at 1 year and 5 years of follow-up for ischemic stroke, systemic embolism, composite stroke, myocardial infarction (MI), intracranial hemorrhage, gastrointestinal bleeding, bleeding at other critical sites, and all-cause death. Compared with warfarin, DOACs were associated with an increased risk for ischemic stroke (RD, 4.97 percentage points [95% CI, 1.27 to 8.57 percentage points]; RR, 1.22 [CI, 1.05 to 1.41]) and composite stroke (RD, 5.56 percentage points [CI, 1.77 to 8.97 percentage points]; RR, 1.23 [CI, 1.07 to 1.42]) and a decreased risk for MI (RD, -1.61 percentage points [CI, -3.17 to -0.03 percentage points]; RR, 0.61 [CI, 0.37 to 0.99]) at the 1-year follow-up. Rivaroxaban increased the risk for ischemic stroke during both short- and long-term follow-up periods. The 2 groups did not differ in risks for bleeding or all-cause death. Limited sample size, lack of detailed information on MS severity, and lack of international normalized ratio measurements. In Asian patients with AF-MS, DOACs were associated with an increased 1-year risk for stroke but a decreased risk for MI compared with warfarin. Research Grants Council of Hong Kong.
In the United States, dietary supplements are regulated as a subcategory of food and therefore are not required to undergo review and approval by the U.S. Food and Drug Administration (FDA). This inadequate regulatory framework has allowed adulterated and mislabeled products to repeatedly enter the market and poses a health threat to the public. In this position paper, the American College of Physicians offers policy recommendations to bolster the FDA's pre- and postmarket regulatory authority for dietary supplements, standardize dietary supplement terminology and data sharing, and implement changes within the health care system to improve care for patients using dietary supplements.
There are few data evaluating the association between glucagon-like peptide-1 receptor agonists (GLP-1RAs) and nonarteritic anterior ischemic optic neuropathy (NAION), which constitutes approximately 75% of ischemic optic neuropathy (ION) cases in adults. To estimate the effect of GLP-1RAs versus sodium-glucose cotransporter-2 inhibitors (SGLT2is) and dipeptidyl peptidase-4 inhibitors (DPP4is) on risk for ION. Observational emulation of a target trial. Large U.S.-based commercial claims database (January 2017 to December 2022). Patients aged 18 to 65 years with type 2 diabetes initiating a GLP-1RA, an SGLT2i, or a DPP4i. The primary outcome was incident ION as a proxy for NAION. Analyses adjusted for more than 80 covariates using inverse probability of treatment weights, and 18-month cumulative incidence and risk differences (RDs) per 10 000 patients were estimated. The 18-month risk for ION was 8.5 versus 5.5 per 10 000 among GLP-1RA users versus SGLT2i users (RD, 3.0 [95% CI, 0.4 to 5.7]) and 7.8 versus 4.2 per 10 000 among GLP-1RA users versus DPP4i users (RD, 3.6 [CI, 1.1 to 6.1]). Corresponding numbers needed to harm were 3333 and 2778, respectively. Among GLP-1RA users, 69 (85.2%) of the 81 ION events occurred in persons older than 50 years and 57 (70.3%) occurred in men. Risk differences were attenuated among metformin monotherapy users (2.0 and 4.1) compared with users of 2 or more diabetes medications (5.7 and 4.0) versus SGLT2is and DPP4is, respectively. Risk differences were higher in men, patients aged 50 years or older, and those with cardiovascular disease or ophthalmic conditions, with minimal differences in women and those younger than 50 years. Diagnostic codes specifically for NAION were lacking. Missing data on key clinical factors (such as body mass index and type 2 diabetes duration) may contribute to residual confounding, leaving uncertainty about whether the observed association is causal. Use of GLP-1RAs was associated with higher 18-month risk for ION than use of SGLT2is and DPP4is, although absolute risk remained very low. Observed differences may reflect residual confounding. National Institutes of Health.
There are concerns about a possible link between glucagon-like peptide-1 receptor agonists (GLP-1RAs) and nonarteritic anterior ischemic optic neuropathy (NAION). To examine whether use of GLP-1RAs increases risk for AION, which predominantly comprises NAION. Nationwide, register-based, cohort study. Sweden, 2013 to 2024. Initiators of GLP-1RAs compared with initiators of sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Anterior ischemic optic neuropathy in the national patient register. Adjusted risk differences (RDs) and risk ratios (RRs) were estimated using propensity score weighting. Median follow-up was 1.6 years (IQR, 0.7 to 3.1 years) for GLP-1RA users and 1.5 years (IQR, 0.7 to 2.9 years) for SGLT-2 inhibitor users. Sixty-two of 107 518 GLP-1RA users and 64 of 185 898 SGLT-2 inhibitor users experienced AION. Risks were 0.04% versus 0.02% (RD, 0.02% [95% CI, 0.00% to 0.03%]; RR, 1.93 [CI, 1.00 to 3.73]) at 1 year and 0.12% versus 0.07% (RD, 0.05% [CI, 0.00% to 0.10%]; RR, 1.69 [CI, 0.95 to 3.01]) at 5 years. The differences were substantially attenuated in analyses restricted to patients receiving metformin at baseline (1 year: RD, 0.01% [CI, -0.01% to 0.02%]; RR, 1.40 [CI, 0.64 to 3.05]; 3 years: RD, 0.01% [CI, -0.02% to 0.04%]; RR, 1.24 [CI, 0.68 to 2.26]; 5 years: RD, 0.02% [CI, -0.04% to 0.08%]; RR, 1.23 [CI, 0.65 to 2.33]). Few outcome events, unmeasured confounding, and limited generalizability to GLP-1RA users without diabetes. The relative risk for AION was higher with GLP-1RA use compared with SGLT-2 inhibitor use in type 2 diabetes. However, absolute risks were small, and the RDs were substantially reduced in analyses restricted to patients receiving metformin to better account for confounding by diabetes severity, suggesting observed increases in risk may reflect residual confounding. Karolinska Institutet, Swedish Society of Medicine, Swedish Research Council, and Region Stockholm.
GIM/FP/GP: [Formula: see text] Cardiology: [Formula: see text] Endocrinology: [Formula: see text] Nephrology: [Formula: see text].
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Hallux rigidus, or osteoarthritis of the first metatarsophalangeal joint (MTPJ), causes pain and functional limitation. No randomized trials have compared surgery with the natural course of the disease. To compare first MTPJ arthrodesis-a widely used surgical intervention-with watchful waiting in reducing walking-related pain in symptomatic hallux rigidus at 12 months after randomization. Single-center, parallel-group, randomized, controlled, superiority trial with 12-month follow-up. (ClinicalTrials.gov: NCT04590313). Orthopedic department of a tertiary care hospital in Finland. Adults aged 40 years or older with radiographically confirmed (Coughlin-Shurnas grade I to III) hallux rigidus with symptoms over a year and a walking pain score of 4 or higher on a numerical rating scale (NRS) of 0 to 10 were eligible. Exclusion criteria included type 1 diabetes mellitus, rheumatoid arthritis, and hallux valgus angle greater than 15°. Participants were randomly assigned in a 1:1 ratio to surgery with first MTPJ arthrodesis using lag-screw and dorsal plating or to watchful waiting. The primary outcome was walking-related pain (NRS of 0 to 10) at 12 months. The prespecified minimal clinically important difference was 1.7 points. Between November 2021 and June 2024, 90 patients were randomly assigned (45 per group). The mean age was 58.1 years, and 89 participants completed the 12-month follow-up. At 12 months, the observed mean walking-related pain was 1.3 in the arthrodesis group and 5.7 in the watchful waiting group (adjusted mean difference, -5.0 points [95% CI, -6.1 to -3.9 points]), exceeding the prespecified minimal clinically important difference and favoring arthrodesis. Single-center design. Among adults aged 40 years or older with painful hallux rigidus, first MTPJ arthrodesis provides a superior and clinically significant reduction in walking-related pain at 12 months compared with watchful waiting. Suomen Lääketieteen Säätiö Foundation, Finland.
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