1.A study of early graft healing after anterior cruciate ligament reconstruction in over-the-top position.
Jue GONG ; Zhiheng WEI ; Mengyang JIA ; Weiming WANG ; Xianxiang XIANG
Chinese Journal of Reparative and Reconstructive Surgery 2025;39(3):307-313
OBJECTIVE:
To compare early graft healing between over-the-top (OTT) and anatomic single-bundle (SB) anterior cruciate ligament (ACL) reconstruction.
METHODS:
A clinical data of 40 patients underwent ACL reconstruction, who admitted between June 2021 and October 2022 and met the selective criteria, was retrospectively analyzed. Among them, 20 patients were treated with OTT reconstruction (OTT group) and 20 with SB reconstruction (SB group). There was no significant difference between groups ( P>0.05) in the gender, age, affected side, disease duration, degree of meniscus injury, body mass index, and preoperative International Knee Documentation Committee (IKDC) score, Lysholm score, pain visual analogue scale (VAS) score, and KT-2000 measurement. At 3, 6, and 12 months, MRI was performed to measure the signal noise quotient (SNQ) of the proximal end, middle, and distal end of the graft in the two groups, as well as at the corner of the graft with lateral femoral condyle and 1 cm around the femoral fixation point in the OTT group, to observe the degree of graft healing. Before operation and at 3, 6, and 12 months, the knee function and pain were evaluated by IKDC score, Lysholm score, and VAS score. Before operation and at 12 months after operation, the KT-2000 measurement was taken to evaluation the knee joint stability.
RESULTS:
All operations were successfully completed in both groups and the incisions healed by first intention. All patients were followed up 12-15 months (mean, 12.9 months), with no significant difference in the follow-up time between groups ( P>0.05). After operation, the IKDC score, VAS score, and Lysholm score improved gradually over time in both groups, with significant differences between different time points ( P<0.05). The differences between groups at 3, 6, and 12 months after operation were not significant ( P>0.05). The anterior and posterior stability of the knee joint improved significantly in both groups at 12 months after operation, and the difference in KT-2000 measurements was significant when compared with the preoperative value ( P<0.05), but the difference of pre- and post-operation between groups was not significant ( P>0.05). At 3, 6, and 12 months after operation, MRI showed that the differences in the SNQ of the proximal end and middle of the grafts between the two groups were not significant ( P>0.05), and the SNQ of distal end was significantly higher in the SB group than in the OTT group ( P<0.05). At each time point, grafts in the OTT group had the highest SNQ at the corner and the lowest at the fixation point, and the differences were significant compared to the other sites ( P<0.05). In the two groups, except for the fixation point, the SNQ of the remaining sites were highest at 6 months and lowest at 12 months ( P<0.05). In addition, there were significant differences in SNQ between the different sites of grafts ( P<0.05), and the SNQ was lowest at proximal end and highest at distal end. At last follow-up, the knee grafts in both groups were in good shape and no graft necrosis or loosening of the internal fixation was observed.
CONCLUSION
The knee joint function and graft healing after OTT reconstruction of ACL are similar to those of SB reconstruction, but it should be noted that the healing at the corner of the graft is slower.
Retrospective Studies
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Treatment Outcome
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Anterior Cruciate Ligament Reconstruction/rehabilitation*
;
Follow-Up Studies
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Tibial Meniscus Injuries/surgery*
;
Patient Positioning/methods*
;
Recovery of Function
;
Pain Measurement
;
Knee Joint/surgery*
;
Humans
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Male
;
Female
;
Adult
;
Wound Healing
2.Homer 1a overexpression alleviates nerve injury in mice with traumatic brain injury by regulating autophagy mediated by PI3K/AKT/mTOR pathway.
Yuan WANG ; Mengyang WANG ; Xiumin ZHANG ; Ming LUO
Chinese Journal of Cellular and Molecular Immunology 2025;41(1):31-37
Objective To investigate the effects and molecular mechanism of Homer protein homolog 1a (Homer 1a) overexpression on nerve injury in mice with traumatic brain injury (TBI). Methods Sixty male C57BL/6 mice were randomly divided into five groups: sham group, TBI group, empty lentivirus (Lv-NC) group, Homer 1a overexpression lentivirus (Lv-Homer 1a) group and Lv-Homer 1a + 740 Y-P group, with 12 mice in each group. The lentivirus was orthotopic injected into the cerebral cortex of mice 5 d before modeling, while 740 Y-P was injected intraperitoneally 1 d before modeling. The TBI model was established using the free-fall impact method, and the modified neurological severity scores (mNSS) of the mice was assessed 72 h post-surgery. The water content of brain tissue was quantified, and the histopathological damage and neuronal loss in brain tissue were assessed using HE staining and Nissl staining respectively. The formation of autophagosomes in brain tissue was observed by transmission electron microscopy. The protein expression levels of Homer 1a, microtubule-associated protein 1 light chain 3B (LC3B), Beclin 1, phosphatidylinositol 3-kinase (PI3K), phosphorylation PI3K(p-PI3K), protein kinase B (AKT), p-AKT, mammalian target of rapamycin (mTOR), and p-mTOR in brain tissue were detected by Western blot analysis. Results Compared to the sham group, the mice in the TBI group exhibited a significant increase in mNSS and cerebral water content. Moreover, severe brain tissue pathological damage was observed, accompanied by a substantial loss of neurons and an increase in autophagosome formation. The protein expressions of Homer 1a and Beclin 1, as well as the protein ratio of LC3B-II/LC3B-I, in brain tissues were significantly elevated, while the protein ratios of p-PI3K/PI3K, p-AKT/AKT, and p-mTOR/mTOR were significantly reduced. Compared to the TBI group, the Lv-Homer 1a group exhibited reduced mNSS and brain water content. Additionally, there was an improvement in pathological brain tissue damage and neuron loss. Furthermore, there was an increase in autophagosome formation and expression of autophagy-related proteins, while the protein ratios of p-PI3K/PI3K, p-AKT/AKT, and p-mTOR/mTOR were decreased. Compared to the Lv-Homer 1a group, the nerve injury in the Lv-Homer 1a+740 Y-P group was exacerbated, accompanied by a reduction in autophagosome formation and expression of autophagy-related proteins, while the PI3K/AKT/mTOR signaling pathway was activated. Conclusion Overexpression of Homer 1a effectively mitigates neurological damage in TBI mice, potentially through modulation of autophagy mediated by the PI3K/AKT/mTOR signaling pathway.
Animals
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TOR Serine-Threonine Kinases/genetics*
;
Autophagy
;
Brain Injuries, Traumatic/pathology*
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Male
;
Proto-Oncogene Proteins c-akt/genetics*
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Phosphatidylinositol 3-Kinases/genetics*
;
Homer Scaffolding Proteins/metabolism*
;
Mice, Inbred C57BL
;
Signal Transduction
;
Mice
3.Clinical Landscape of Therapeutic Cancer Vaccines: Challenges and Opportunities
Shupeng LIU ; Mengyang YU ; Xiaofei WU ; Hongyun WANG
Medical Journal of Peking Union Medical College Hospital 2024;15(6):1356-1363
To explore the status and characteristics of clinical trials of therapeutic cancer vaccines, and provide the overall trend of clinical translational research of therapeutic cancer vaccines. The ClinicalTrial registration platform was employed to retrieve relevant clinical trial information of therapeutic cancer vaccines from 2002 to 2023. The current clinical landscape of therapeutic cancer vaccines was analyzed from the perspectives of the number of registrations, types of vaccines, trial design, and geographical distribution. A total of 1563 clinical trials for therapeutic cancer vaccines were obtained from 2002 to 2023, with an average annual registration of approximately 70 trials. Among these, phase Ⅰ trials accounted for 976 (62.4%, 976/1563), phase Ⅱ trials for 474 (30.3%, 474/1563), phase Ⅲ trials for 68 (4.4%, 68/1563), and other types for 45 (2.9%, 45/1563). Clinical trials from phase Ⅰ to phase Ⅲ were conducted in multiple regions worldwide, with multicenter clinical trials totaling 482 (31.8%) and single-center clinical trials totaling 1036 (68.2%). The main types of vaccines were cell vector vaccines (38.7%, 588/1518) and protein/peptide vaccines (34.1%, 518/1518), with the primary research designs being single-arm studies (55.3%, 840/1518) and randomized controlled trials (27.8%, 422/1518). The top five indications for the vaccines were melanoma (16.5%, 251/1518), glioblastoma (8.9%, 135/1518), breast cancer (8.6%, 130/1518), prostate cancer (8.5%, 129/1518), and lung cancer (8.1%, 123/1518). The overall development of clinical trials for therapeutic cancer vaccines has been stable and primarily focused on exploratory trials. The main types of vaccines were cell vector vaccines, and the main research designs were single-arm studies and randomized controlled trials. The vaccines were commonly indicated for melanoma, glioblastoma, and breast cancer. Currently, there are significant challenges in the clinical translation in this field, which may be due to the complexity of the immune microenvironment, patient heterogeneity, and the challenges in vaccine design and preparation. With the application of high-throughput technologies such as proteomics, genomic sequencing, and bioinformatics, it is expected that barriers in the research of therapeutic cancer vaccines would be overcome, thus leading to a better clinical translation landscape.
4.Protective effects of cinnamaldehyde on benzene-induced immune and oxidative stress injury in mice
Mengyang LI ; Gui WANG ; Yamei QIAO ; Pingyu WANG ; Min JIN ; Dong YANG ; Junwen LI
Military Medical Sciences 2024;48(1):44-51
Objective To investigate the effects of cinnamaldehyde,the main active component of cinnamon,on benzene-induced immune injury in mice and the related mechanism.Methods Forty male BALB/c mice were randomly divided into the control group,model group(benzene 500 mg/kg),cinnamaldehyde low,medium and high dose groups(5,25,50 mg/kg),with 8 mice in each group.Except the control group,mice in each group were treated with benzene by intragastric administration daily to induce immune and oxidative stress damage,but the intervention group was treated with cinnamaldehyde 5 times/week for 3 weeks.After medication,peripheral blood was collected 24 h after the last gavage for blood cell count,and the changes in body weight of mice in each group were observed.The pathological structure of the spleen and thymus was observed via hematoxylin-eosin(HE)staining.Peripheral blood mononuclear cells(PBMCs)of mice were extracted and the amounts of reactive oxygen species(ROS)and ATP in mitochondria were measured.Plasma levels of malondialdehyde(MDA)were measured using the barbituric acid method,the activity of glutathione peroxidase(GSH-PX)in plasmawith the dithiodinitrobenzoic acid methodand the activity of total superoxide dismutase(SOD)in plasma using the hydroxylamine method.Results After exposure to benzene,the body weight of the model group became lower(P<0.05).The spleen and thymus were damaged,and the indexes of the spleen and thymus were decreased(P<0.05).Counts of peripheral white blood cells and lymphocyteswere decreased(P<0.05).The activities of GSH and SOD in plasma were decreased(P<0.05),but the content of MDA was increased(P<0.05).The amount of mitochondrial ROS in PBMC was increased,while the ATP content was decreased(P<0.05).The weight of mice increased after treatment with cinnamaldehyde.The spleen and thymus tissues recovered well,and the indexes of the spleen and thymus were increased(P<0.05).Counts of peripheral white blood cells and lymphocytesin the high dose cinnamaldehyde group were increased(P<0.05).The activities of GSH and SOD in plasma were increased,while the content of MDA was decreased(P<0.05).The amount of mitochondrial ROS in PBMC was decreased,but the ATP content was increased(P<0.05).Treatment with cinnamaldehyde could alleviate the damage to the mitochondrial function of PBMC induced by benzene in mice,and 50 mg/kg was the best dose(P<0.05).The therapeutic effect of cinnamaldehyde had a dose-response relationship.Conclusion Cinnamaldehyde can inhibit benzene-induced immune injury and oxidative stress injury in mice by delivering an antioxidant effect and improving mitochondrial enhancement of PBMC.
5.Syndrome of inappropriate secretion of thyrotropin: Differential diagnosis
Shasha WANG ; Zhizhen LI ; Yanyan ZHAO ; Huijuan ZHANG ; Xialian LI ; Guijun QIN ; Lili ZHENG ; Yanxia LIU ; Mengyang ZHANG ; Feng GUO
Chinese Journal of Endocrinology and Metabolism 2024;40(3):212-218
Objective:Through comprehensive analysis of symptoms and signs, biochemistry, imaging, and dynamic tests, to explore the diagnosis and differential diagnosis of thyrotropin-secreting pituitary adenoma(TSH adenoma) and syndrome of resistance to thyroid hormone(RTH).Methods:A retrospective analysis was conducted on clinical data from 14 patients who visited the First Affiliated Hospital of Zhengzhou University from July 2016 to September 2022, exhibiting elevated levels of free thyroxine(FT4) and free triiodothyronine(FT3) in the presence of increased TSH.Results:There were 7 cases of TSH adenoma and 7 cases of RTH, with the average age of diagnosis at 40.0 years and 26.6 years, respectively. Thirteen patients showed thyrotoxicosis or occasional palpitation, some with pituitary occupancy manifestations or abnormal growth and development; One patient presented with neck thickening. Sex hormone binding globulin was elevated in 3 cases of TSH adenoma. Pituitary magnetic resonance imaging showed that all 7 cases of TSH adenoma were macroadenomas and 1 case of RTH was microadenoma. The octreotide suppression test in 13 patients was inhibited, but there was a significant difference in the inhibition rate of 24 h/2 h TSH inhibition rate of TSH adenoma and RTH, ranging from 46.6% to 83.9% and 4.6% to 28.8% respectively. Six cases of RTH had thyroid hormone receptor β mutation.Conclusion:Syndrome of inappropriate secretion of thyrotropin is a rare condition, mainly including TSH adenoma and RTH. The diagnosis and differentiation of the two conditions require comprehensive assessment incorporating family history, symptoms and signs, laboratory tests, dynamic test, and genetic test. Among these, the 24 h/2 h TSH inhibition rate of octreotide suppression test can effectively distinguish TSH adenoma from RTH.
6.A comparative study on the clinical manifestations of children infected with erythromycin-resistant Bordetella pertussis of ptxP1 and ptxP3 genotypes
Mengyang GUO ; Bingsong WANG ; Lin YUAN ; Zhen LI ; Yahong HU ; Qianqian DU ; Wei SHI ; Yajuan WANG ; Kaihu YAO
Chinese Journal of Applied Clinical Pediatrics 2024;39(2):89-93
Objective:To determine the erythromycin resistance of Bordetella pertussis isolates and their ptxP1 and ptxP3 phenotypic composition and compare clinical manifestations of children with pertussis caused by the two types of strains. Methods:This was a cross-sectional study, the pertussis cases diagnosed using bacterial culture from January 2019 to December 2022 in Beijing Children′s Hospital and the First People′s Hospital of Wuhu were collected.Any suspected Bordetella pertussis colonies were identified by the slide agglutination test.The susceptibility of isolates to erythromycin was detected by the E-test and K-B test.The ptxP gene was amplified by polymerase chain reaction and sequenced to determine its genotype. t-test, Mann-Whitney U-test, Chi-square test and Fisher′s exact test were use to statistical analysis. Results:A total of 192 strains of Bordetella pertussis were identified, including 188 (97.9%) erythromycin-resistant strains.Among the 188 strains, 30.3%(57/188) belonged to the ptxP1 genotype and 69.7%(131/188) belonged to the ptxP3 genotype.In children aged below 1 year old, the incidence of paroxysmal cough caused by infection with the ptxP3 strain was higher than that with the ptxP1 strain (57.1% vs.29.4%, P<0.05), and children infected with the ptxP3 strain were more likely to develop apnea or asphyxia (23.8% vs.17.6%), post-tussive vomiting (44.4% vs.32.4%), whooping cough (72.0% vs.50.0%) and pneumonia or bronchitis (85.7% vs.73.5%) compared to those infected with the ptxP1 strain, but the differences were not statistically significant(all P>0.05). In children aged 1 year old and above, the white blood cell count of children infected with the ptxP1 strain was higher than that of infections with the ptxP3 strain [13.5(9.9, 24.5)×10 9/L, 10.3 (7.0, 16.4)×10 9/L, P<0.05], and children infected with the ptxP1 strain were more likely to contract other pathogen infections than those infected with the ptxP3 strain (17.4% vs.4.4%, P>0.05). Conclusions:ptxP3 erythromycin-resistant Bordetella pertussis has become the main pathogen of pertussis.Infants with pertussis caused by the ptxP3 erythromycin-resistant strain show more significant manifestations and a higher possibility of severe symptoms than those infected with the ptxP1 erythromycin-resistant strain.
7.Clinical Landscape of Therapeutic Cancer Vaccines: Challenges and Opportunities
Shupeng LIU ; Mengyang YU ; Xiaofei WU ; Hongyun WANG
Medical Journal of Peking Union Medical College Hospital 2024;15(6):1356-1363
To explore the status and characteristics of clinical trials of therapeutic cancer vaccines, and provide the overall trend of clinical translational research of therapeutic cancer vaccines. The ClinicalTrial registration platform was employed to retrieve relevant clinical trial information of therapeutic cancer vaccines from 2002 to 2023. The current clinical landscape of therapeutic cancer vaccines was analyzed from the perspectives of the number of registrations, types of vaccines, trial design, and geographical distribution. A total of 1563 clinical trials for therapeutic cancer vaccines were obtained from 2002 to 2023, with an average annual registration of approximately 70 trials. Among these, phase Ⅰ trials accounted for 976 (62.4%, 976/1563), phase Ⅱ trials for 474 (30.3%, 474/1563), phase Ⅲ trials for 68 (4.4%, 68/1563), and other types for 45 (2.9%, 45/1563). Clinical trials from phase Ⅰ to phase Ⅲ were conducted in multiple regions worldwide, with multicenter clinical trials totaling 482 (31.8%) and single-center clinical trials totaling 1036 (68.2%). The main types of vaccines were cell vector vaccines (38.7%, 588/1518) and protein/peptide vaccines (34.1%, 518/1518), with the primary research designs being single-arm studies (55.3%, 840/1518) and randomized controlled trials (27.8%, 422/1518). The top five indications for the vaccines were melanoma (16.5%, 251/1518), glioblastoma (8.9%, 135/1518), breast cancer (8.6%, 130/1518), prostate cancer (8.5%, 129/1518), and lung cancer (8.1%, 123/1518). The overall development of clinical trials for therapeutic cancer vaccines has been stable and primarily focused on exploratory trials. The main types of vaccines were cell vector vaccines, and the main research designs were single-arm studies and randomized controlled trials. The vaccines were commonly indicated for melanoma, glioblastoma, and breast cancer. Currently, there are significant challenges in the clinical translation in this field, which may be due to the complexity of the immune microenvironment, patient heterogeneity, and the challenges in vaccine design and preparation. With the application of high-throughput technologies such as proteomics, genomic sequencing, and bioinformatics, it is expected that barriers in the research of therapeutic cancer vaccines would be overcome, thus leading to a better clinical translation landscape.
8.Effects of adjuvant arthritis on renal function and expression of organic anion transporter 3 in rats
Mengyang LI ; Qianlei WANG ; Wei WEI ; Chun WANG
Acta Universitatis Medicinalis Anhui 2024;59(9):1495-1500
Objective To investigate the effects of adjuvant arthritis(AA)on renal function and the expression of organic anion transporter 3(OAT3)in rats.Methods The AA model was established via intradermal injection of Freund's complete adjuvant into the right hind toe of the rats.Blood and urine were collected at fixed time points to observe the dynamic changes of renal injury indicators.The kidney injury was observed by HE staining.Immuno-histochemistry and Western blot were used to detect the expression levels of OAT3 protein and inflammatory factors interleukin-6(IL-6),interleukin-1 β(IL-1 β)and tumor necrosis factor-α(TNF-α)in renal cortex.Results Compared with the normal group,the arthritis index score,the secondary paw swelling,the number of joint swell-ing,and the whole body score of AA rats significantly increased(P<0.05).The X-ray results showed that the AA model rats had soft tissue edema and bone deformity.Biochemical indicators showed that the renal injury indicators of AA rats were significantly abnormal.The results of immunohistochemistry and Western blot showed that the ex-pression level of OAT3 in renal cortex of AA rats significantly decreased,while the expression levels of inflammato-ry factors IL-6,TNF-α and IL-1 β significantly increased(P<0.05).Conclusion The renal injury of AA rats may be related to the decreased expression level of OAT3 and the increased expression level of inflammatory factors in kidney.
9.Effects of Different Pellet Feed Hardness on Growth and Reproduction,Feed Utilization Rate,and Environmental Dust in Laboratory Mice
Dong WU ; Rui SHI ; Peishan LUO ; Ling'en LI ; Xijing SHENG ; Mengyang WANG ; Lu NI ; Sujuan WANG ; Huixin YANG ; Jing ZHAO
Laboratory Animal and Comparative Medicine 2024;44(3):313-320
Objective To study the effects of different pellet feed hardness on the growth and reproduction,feed utilization rate,and environmental dust in laboratory mice.Methods One hundred of fifty 50 3-week-old SPF-grade C57BL/6JGpt and 150 ICR laboratory mice were randomly divided into three groups,with an equal number of males and females.They were fed diets with different hardness of 18.62 kg,23.15 kg,and 27.89 kg.Body weight,feed utilization rate,and dust levels in cages were recorded and calculated for mice aged 3-10 weeks.Forty-five 6-week-old male mice and ninety 4-week-old female mice from each strain were randomly divided into three groups and fed pellet feeds with three different hardness levels.After 2 weeks of adaptation to the same hardness feed,the mice were paired at a 1:2 male-to-female ratio and monitored for reproductive data for 3 months.Results At the age of 4 weeks,the body weight of male C57BL/6JGpt mice in 23.15 kg group was significantly higher than that in the 18.62 kg and 27.89 kg groups(P<0.01),and the body weight of females in the 18.62 kg group was significantly higher than that in the 27.89 kg group(P<0.05).There was no significant difference in body weight among ICR mice aged 3-10 weeks across different feed hardness groups(P>0.05).For both strains,feed utilization rate for males was higher than that for females across different feed hardness groups at all weeks of age(P<0.01).Compared to the 27.89 kg group,both the 18.62 kg and 23.15 kg groups showed a significant increase in the 50-mesh dust levels in cages for both strains aged 4-8 weeks(except for 7-week-old C57BL/6JGpt mice)(P<0.05).For both C57BL/6JGpt and ICR mice,there was no significant difference in basic reproductive performance such as interval between the first litter and the monthly production index among the three feed hardness groups during the experimental period(P>0.05).However,the monthly production index of C57BL/6JGpt mice first increased and then decreased with the increase of feed hardness,while that of ICR mice increased with increasing feed hardness,though these differences were not statistically significant(P>0.05).Conclusion Different strains and genders had different tolerance to feed hardness.C57BL/6JGpt mice are more adapted to lower hardness feeds,while ICR mice are better suited to slightly higher hardness feeds.
10.Construction of Longitudinal Comprehensive Evaluation Model of Disease Treatment Quality and Its Application in CIS
Lei YU ; Mengyang LIU ; Chao WANG
Chinese Journal of Health Statistics 2024;41(5):662-666,670
Objective Construct a longitudinal comprehensive evaluation model of disease treatment quality to evaluate the quality of treatment for cerebral ischemic stroke(CIS).Methods The latent variable measurement model was combined with polynomial and multilevel regression to establish a longitudinal comprehensive evaluation model of disease treatment quality,the MCMC was used for parameter estimation.Simulation studies were conducted to determine the applicable conditions of the model,the accuracy of model parameter estimation was evaluated by root mean square error and rank correlation coefficient,the results were compared with the latent growth curve model(LGCM).Results A comprehensive model that can be used to evaluate the longitudinal change,trend change and the impact of covariates in the quality of disease care was constructed.The number of evaluation objects has a little effect on the model effect.When the number of observation time was 6 and the number of evaluation indicators was 20,the model could obtain the treatment quality and change trend of the evaluation object at different time points.The mean rank correlation coefficient between the estimated value of treatment quality and the true value was 0.8128,which was higher than that of LGCM(0.7610).The mean RMSE between the estimated value of the covariate regression coefficient and the true value was 0.3756,which was lower than that of LGCM(0.448).The more observation time and evaluation indexes,the more accurate the longitudinal comprehensive evaluation model was,and it was always higher than LGCM.From 2011 to 2016,the average CIS quality of care comprehensive score of hospitals increased by 0.9256,secondary and tertiary hospitals increased by 0.9432 and 1.321,teaching and non-teaching hospitals increased by 1.4904 and 1.1155.Conclusion The longitudinal comprehensive evaluation model can comprehensively and reasonably evaluate the quality of disease treatment and its longitudinal changes,and analyze the impact of differences in evaluation objects on the change trend.The quality of CIS treatment in China is generally good,and the changing trend is affected by the level of hospitals and teaching status.The results of this study can provide reference for the subsequent development of targeted treatment quality intervention measures and continuous improvement of treatment quality.


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