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  • 1
    Electronic Resource
    Electronic Resource
    Characteristic findings of hepatocellular carcinoma: An evaluation with comparative study of US, CT, and MRI (1992)
    Springer
    Abdominal imaging 17 (1992), S. 245-249 
    Details
    ISSN: 1432-0509
    Keywords: Liver, neoplasms ; Liver, magnetic resonance imaging ; Liver, computed tomography ; Liver, ultrasonography
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract The sensitivity, specificity, and accuracy of ultrasonography (US), dynamic incremented computed tomography (CT) with delayed phase imaging, and magnetic resonance imaging (MRI) with or without Gd-DTPA were studied for detecting the characteristic appearances of hepatocellular carcinomas (HCC): fibrous capsules, fibrous septa, and mosaic appearances. Results were prospectively evaluated in 30 patients who subsequently underwent hepatic lobectomies or segmentectomies. Pathologic evaluations of the resected liver specimens demonstrated fibrous capsules in 20 tumors (66.7%), fibrous septa in 13 tumors (43.3%), and mosaic appearances in 19 tumors (63.3%). The accuracies for fibrous capsules were 71.4% (20 of 28) for US, 81.5% (22 of 27) for CT, and 92.3% (24 of 26) for MRI. The accuracies for fibrous septa were 57.1% (16 of 28) for US, 59.3% (16 of 27) for CT, and 73.1% (19 of 26) for MRI. The accuracies for mosaic appearances were 71.4% (20 of 28) for US, 51.9% (14 of 27) for CT, and 69.2% (18 of 26) for MRI. Gd-DTPA administrated MRI showed higher accuracies than did conventional MRI for all manifestations. In conclusion, the fibrous capsules of HCCs were readily detected by CT and MRI. Gd-DTPA administration demonstrated an advantage in clarifying fibrous capsules, as well as fibrous septa and mosaic appearances.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF01888559
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  • 2
    Electronic Resource
    Electronic Resource
    DNA ploidy of primary hepatocellular carcinoma and pulmonary metastases (1992)
    Springer
    Clinical & experimental metastasis 10 (1992), S. 337-344 
    Details
    ISSN: 1573-7276
    Keywords: DNA content ; hepatocellular carcinoma ; pulmonary metastasis
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: To better comprehend the differences in deoxyribonucleic acid (DNA) content between a primary hepatocellular carcinoma (HCC) and pulmonary metastatic nodules, tissue specimens taken at autopsy of 25 patients who had not received any drugs to treat the malignancy were examined using microspectrophotometry. The DNA distribution patterns were classified into Types I–III, and low (Types I and II) or high (Type III) ploidies, according to DNA distribution. Changes in the DNA content from high to low ploidies, namely DNA ploidy reduction from the primary lesion to pulmonary metastatic lesions, was evident in 9 of the 25 patients (36%), and changes from low to high were noted in 2 of the 25 patients (8%). The remaining 14 (56%) showed no evidence of changes in the DNA ploidy pattern. Reduction of DNA ploidy seen in HCC and its metastatic lesions in the lung may be one of the aspects of clonal evolution or selection mechanisms during the progression of tumor growth and metastasis.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF00058173
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  • 3
    Electronic Resource
    Electronic Resource
    Operative results in 143 patients with hepatocellular carcinoma (1993)
    Springer
    World journal of surgery 17 (1993), S. 663-667 
    Details
    ISSN: 1432-2323
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Résumé Les dossiers de 143 patients ayant eu une résection hépatique pour carcinome hépatocellulaire ont été analysés. Deux périodes d'observation ont été comparées: la première entre 1970 et 1982 et la seconde entre 1983 et 1990, la limite étant déterminée par l'utilisation de la coagulation par micro-onde d'une part et le bistouri à ultra-sons, d'autre part. Pendant la première période, les interventions pratiquées ont été une lobectomie étendue dans un cas, 12 lobectomies simples, 9 segmentectomies, et 26 hépatectomies partielles. Pendant la seconde période, ont été pratiquées deux lobectomies étendues, 7 lobectomies simples, 9 segmentectomies, 36 sous-segmentectomies et 41 hépatectomies partielles. Les mortalité opératoire et hospitalière ont été respectivement de 16.7% et 22.9%, et de 1.1% et 8.4% dans les deux périodes d'observation. La mortalité globale était significativement plus basse pendant la deuxième période par rapport à la première. Les complications postopératoires ont été de 62.5% et de 48.4% dans les deux périodes d'observation. La perte sanguine peropératoire a été considérablement moindre pendant la deuxième période. L'amélioration des résultats de la chirurgie hépatique après 1983 est directement liée à l'introduction de l'échographie peropératoire, la coagulation par microondes et le bistouri à ultra-sons.
    Abstract: Resumen Se revisaron 143 pacientes sometidos a resección hepática por carcinoma hepatocelular en nuestro departamento. La revisión fue realizada sobre dos periodos, de 1970 a 1982 (primer periodo) y de 1983 a 1990 (segundo periodo), correspondientes a los periodos antes y después de la introducción de las técnicas de cirugía hepática que utilizan el coagulador tisular de microondas y el disector ultrasónico. En el primer periodo un paciente fue sometido a lobectomía ampliada, 12 a lobectomía, 9 a segmentectomía y 26 a hepatectomia parcial. En el segundo periodo dos pacientes fueron sometidos a lobectomia ampliada, 7 a lobectomía, 9 a segmentectomía, 36 a subsegmentectomía y 41 a hepatectomía parcial. La mortalidad operatoria y la mortalidad hospitalaria fueron 16.7% y 22.9% en el primer periodo y 1.1% y 8.4% en el segundo, respectivamente. La tasa global de mortalidad apareció significativamente menor en el segundo periodo. El tamaño de los tumores fue significativamente mayor en el primer periodo. La pérdida intraoperatoria de sangre fue significativamente menor en el segundo periodo. La curva de sobrevida fue mejor en los pacientes del segundo periodo. Los satisfactorios resultados registrados en el segundo periodo se deben a la introduccion de la ultrasonografía intraoperatoria, de la coagulacion tisular de microondas y del disector ultrasónico en la cirugía hepática.
    Notes: Abstract A total of 143 patients who underwent hepatic resection for hepatocellular carcinoma in our department were reviewed. The review was conducted for two periods: 1970–1982 (early period) and 1983–1990 (late period), that is, the periods before and after introduction of the hepatic surgical technique involving the use of a microwave tissue coagulator and ultrasonic dissector. One patient underwent extended lobectomy, 12 lobectomy, 9 segmentectomy, and 26 partial hepatectomy during the early period. Two patients underwent extended lobectomy, 7 lobectomy, 9 segmentectomy, 36 subsegmentectomy, and 41 partial hepatectomy during the late period. Operative mortality and hospital mortality were 16.7% and 22.9% during the early period and 1.1% and 8.4% during the late period, respectively. The overall mortality rate was significantly lower during the late period than during the early period. Postoperative complications developed in 62.5% of the patients with hepatic resection during the early period and in 48.4% of the patients during the late period. The size of tumors during the early period was significantly greater than that during the late period. Intraoperative blood loss during the late period was significantly lower than that during the early period. The survival curve was better among patients who underwent hepatic resection during the late period than among those during the early period. The satisfactory results during the late period are due to the introduction of intraoperative ultrasonography, microwave tissue coagulation, and ultrasonic dissection for hepatic surgery.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF01659138
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  • 4
    Electronic Resource
    Electronic Resource
    Enhancement of biliary carcinogenesis in hamsters by cholecystokinin (1995)
    Springer
    World journal of surgery 19 (1995), S. 847-850 
    Details
    ISSN: 1432-2323
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Résumé Nous avons récemment développé un nouveau modèle pour reproduire les cancers biliares chez le cochon d'Inde. Nous avons évalué les effects de la cholécystokinine (CCK) qui a une action trophique sur le tube gastro-intestinal et sur le système pancréaticobiliaire, sur la carcinogénèse biliaire chez le cochon d'Inde. Les cochons d'Inde traités avec du N-nitrosobis(2-oxopropyl) amine (BOP) ont été divisées en quatre groupes. Dans le groupe I, on a injecté une gélatine hydrolysée, un solvant de la CCK en sous-cutanée. Dans les groupe II et III, on a injecté 2.5 et 25 μg/kg, respectivement. Dans le groupe IV, on a administré de la loxiglumide, un antagoniste des récepteurs de la CCK. La CCK a potentialisé de façon significative l'effet carcinogénique de la BOP dans les voies biliaires intra- et extra-hépatiques mais pas dans la vésicule ou dans le pancréas. La loxiglumide exerce un effet inhibiteur sur la carcinogenèse des voies biliaires intrahépatiques.
    Abstract: Resumen Recientemente adoptamos un nuevo modelo para la inducción rápida y reproducible de carcinoma biliar en el hámster. En el presente estudio se hizo la evaluación de los efectos de la colecistocinina (CCK), que posee acción trófica sobre el tracto gastrointestinal y sobre el sistema pancreático biliar, en cuanto a la carcinogénesis biliar en este modelo de hámster. Los hamsters tratados con N-nitrosobis(2-oxopropil)amina (BOP) fueron divididos en 4 grupos. En el grupo I se inyectó gelatina hidrolizada, un solvente de la CCK, por vía subcutánea. En los grupos II y III se administró CCK 2.5 y 25 μg/kg, respectivamente. En el grupo IV se administró loxiglumida, un antagonista de los receptores de CCK. La CCK promovió en forma significativa el efecto carcinogénico de la BOP en los canales biliares intra y extrahepáticos, pero no en la vesícula biliar o el páncreas. La loxiglumida ejerció un efecto inhibitorio de la carcinogénesis en la vía biliar intrahepática.
    Notes: Abstract We recently developed a new model for rapid and reproducible induction of biliary carcinoma in hamsters. In the present study, we evaluated the effects of cholecystokinin (CCK), which has a trophic action on the gastrointestinal tract and on the pancreaticobiliary system, on biliary carcinogenesis in this hamster model. Hamsters treated with N-nitrosobis (2-oxopropyl) amine (BOP) were divided into four groups: In Group I, hydrolyzed gelatin, a solvent of CCK, was injected subcutaneously. In Groups II and III, CCK 2.5 and 25 μg/kg were administered, respectively. In Groups IV loxiglumide, a CCK receptor antagonist, was administered. CCK significantly promoted the carcinogenetic effect of GOP in the intra- and extrahepatic bile ducts but not in the gallbladder or pancreas. Loxiglumide exerted an inhibitory effect on carcinogenesis in the intrahepatic bile duct.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF00299782
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  • 5
    Electronic Resource
    Electronic Resource
    The indocyanine green test enables prediction of postoperative complications after hepatic resection (1987)
    Springer
    World journal of surgery 11 (1987), S. 678-681 
    Details
    ISSN: 1432-2323
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Résumé Les auteurs ont étudié les suites opératoires de 50 malades qui avaient subi une résection hépatique en comparant les taux de rétention de l'indocyanine green (ICG) mesurés lors du 3ème jour post-opératoire par rapport à ceux appréciés immédiatement après l'opération. Ce rapport étant l'expression de l'index ICG du parenchyme restant. Le groupe A de 22 malades avec un index restant de moins de 1.0, (qui signifie le taux de rétention de ICG à 15 mm lors du 3ème jour post-opératoire) a montré une amélioration par comparaison aux faits qui ont succédé immédiatement à l'intervention. Un groupe B de 28 malades chez qui l'index au 3ème jour était supérieur à 1.0, indiquant par conséquent une élévation du taux de clarance de l'ICG après résection hépatique, a été individualisé. De sérieuses complications comprenant infection abdominale et hyperbilirubinémie se sont manifestées en post-opératoire respectivement chez 2 (9.1%) du groupe A et 16 (57.1%) du groupe B (p〈0.001). Un malade (4.5%) du groupe A décéda cependant que 9 malades (32.1%) du groupe B moururent pendant l'hospitalisation (p〈0.02). Il ne fut pas constaté de différence significative en ce qui concerne la fonction hépatique préopératoire et les paramètres cliniques. Ces observations suggèrent que l'amélioration du taux de la clairance de l'ICG au 3ème jour post-opératoire par comparaison au taux déterminé immédiatement après l'intervention permet de préjuger des suites post-opératoire après résection hépatique.
    Abstract: Resumen Hemos valorado la evolución postoperatoria de 50 pacientes sometidos a resección hepática, utilizando la relación entre las tasas de retención del verde de indocianina (VIC) medidas en el tercer día postoperatorio y los valores estimados inmediatamente después de la operación. Esta relación fue expresada en forma del indice VIC de remanente hepático. El grupo A incluyó 22 pacientes con un indice de menos de 1.0, lo cual significa que la tasa de retención VIC a los 15 minutos en el tercer día postoperatorio mostró mejoría en comparación con los hallazgos inmediatamente al término de la operación. En el grupo B hubo 28 pacientes cuyos indices en el tercer día postoperatorio fue superior a 1.0, lo cual indica exacerbación de la tasa de depuración de VIC después de la resección hepática. Se presentaron complicaciones postoperatorias graves, incluso sepsis intraabdominal e hiperbilirrubinemia en 2 (9.1%) en el grupo A y 16 (57.1%) en el grupo B (p〈0.001). Murió un paciente (4.5%) en el grupo A contra 9 pacientes (32.1%) que murieron en el grupo B en el curso de la hospitalización (p〈 0.02). No se observaron diferencias significativas en cuanto a las pruebas preoperatorias de función hepática o los parámetros clínicos. Estas observaciones sugieren que la mejoría en la tasa de depuración de VIC en el tercer día postoperatorio, comparada con aquella inmediatamente al término de la operación, es un paramétro de utilidad en la predicción del curso postoperatorio de pacientes hepatectomizados.
    Notes: Abstract We evaluated the postoperative course of 50 patients who underwent hepatic resection, using the ratio of indocyanine green (ICG) retention rates measured on the third postoperative day to values estimated immediately after the operation. This ratio was expressed as the remnant liver ICG index. Group A included 22 patients with a remnamt liver ICG index of less than 1.0, which meant that the ICG retention rate at 15 minutes on the third postoperative day showed improvement, compared to events immediately after the operation. In group B, there were 28 patients whose index on the third postoperative day was over 1.0, thereby indicating exacerbation of the ICG clearance rate after hepatic resection. Serious complications including intraabdominal sepsis and hyperbilirubinemia occurred postoperatively in 2 (9.1%) in group A and 16 (57.1%) in group B (p〈0.001). One patient (4.5%) in group A died, while 9 patients (32.1%) in group B died during hospitalization (p〈 0.02). There were no significant differences with regard to preoperative liver function and clinical parameters. These observations suggest that improvement in the ICG clearance rate on the third postoperative day, compared to that immediately after the operation, is useful to predict the postoperative course of hepatectomized patients.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF01655848
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  • 6
    Electronic Resource
    Electronic Resource
    Tauroursodeoxycholate and Cholestyramine Enhance Biliary Carcinogenesis in Hamsters (2000)
    Springer
    World journal of surgery 24 (2000), S. 22-26 
    Details
    ISSN: 1432-2323
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract. The aim of this study was to examine whether tauroursodeoxycholate (TUDC) and cholestyramine resin (CR) enhance biliary carcinogenesis in the hamster model. A cholecystoduodenostomy with dissection of the extrahepatic bile duct on the distal end of the common duct was performed on Syrian hamsters. The hamsters were then divided randomly into 3 groups: control group, TUDC-treated group, and CR-treated group. All animals received N-nitrosobis(2-oxopropyl)amine (BOP) to initiate pancreaticobiliary cancer. The experiment was terminated at week 16 and the number of neoplastic lesions was counted microscopically. In the TUDC group, the intrahepatic biliary carcinogenesis was more accelerated than that observed in the control group, but no promoting effect was seen in the pancreas, gallbladder, or extrahepatic bile duct. In the CR group, both the intrahepatic biliary and the gallbladder carcinogenesis were inhibited compared with that observed in the control group and the TUDC group. TUDC enhanced the intrahepatic bile duct carcinogenesis, whereas CR inhibited both the intrahepatic bile duct and the gallbladder carcinoma. Bile acids were suggested to promote biliary carcinoma in the hamster model.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s002689910005
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  • 7
    Electronic Resource
    Electronic Resource
    Can hepatic failure after surgery for hepatocellular carcinoma in cirrhotic patients be prevented? (1990)
    Springer
    World journal of surgery 14 (1990), S. 123-127 
    Details
    ISSN: 1432-2323
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Résumé Pour étudier les causes d'insuffisance hépatocellulaire postopératoire chez le cirrhotique ayant eu une résection hépatique pour carcinome hépatocellulaire, nous avons analysé les données chez 126 patients cirrhotiques opérés entre 1977 et 1987. On a revu les dossiers de 102 patients ayant eu une évolution postopératoire satisfaisante (groupe de survie) et de 24 patients qui ont développé une insuffisance hépatique et qui en sont morts (groupe d'insuffisance hépatocellulaire). On n'a pas pu mettre en évidence de différence de fonction hépatique préopératoire entre les 2 groupes. Du point de vue histologique, l'inflammation était modérée ou sévère chez 20 (83%) des 24 patients du 2e groupe. On a pratiqué des résections majeures (hépatectomies et hépatectomies élargies) plus nombreuses dans ce groupe. La perte sanguine périopératoire moyenne était de 1,945 et 4,322 g, respectivement, dans le groupe de survie et dans celui d'insuffisance hépatocellulaire. Cette différence est statistiquement significative (p 〈 0.01). On a observé des complications majeures chez 22 (22%) des 102 patients dans le groupe des survivants. On a observé des complications majeures suivies d'insuffisance hépatique chez 21 (88%) des 24 patients dans le deuxième groupe, cette différence étant hautement significative (p 〈 0.001). A la lumière de ces faits, nous proposons: (a) de faire une biopsie hépatique avant toute résection, (b) de limiter les pertes sanguines à 2000 g, et (c) d'administrer en période postopératoire les soins intensifs nécessaires pour éviter les complications susceptibles de provoquer l'insuffisance hépatique.
    Abstract: Resumen Con el propósito de elucidar la causa de la falla hepática postoperatoria en los pacientes cirróticos sometidos a resección por carcinoma hepatocelular, hemos analizado la información clínica correspondiente a 126 cirróticos tratados quirúrgicamente entre 1977 y 1987. Se revisaron las historias clínicas de 102 pacientes que tuvieron una buena evolución postoperatoria (grupo de sobrevivientes) y de 24 que desarrollaron falla hepática y murieron (grupo de falla hepática). No se encontró diferencia aparente en cuanto al estado preoperatorio de la función hepática entre los 2 grupos. Desde el punto de vista histológico, se halló actividad inflamatoria de grado moderado a severo en el hígado de 20 (83%) de los 24 pacientes del grupo de falla hepática. Las resecciones mayores (lobectomía y lobectomía ampliada) fueron más frecuentes en el grupo de falla hepática. El promedio de pérdida perioperatoria de sangre fue de 1,945 g y 4,322 g en los grupos de sobrevivientes y de falla hepática, respectivamente, lo cual représenta una diferencia significativa (p 〈 0.01). Complicaciones postoperatorias mayores se presentaron en 22 (22%) de los 102 pacientes del grupo de sobrevivientes, en tanto que las complicaciones mayores seguidas de falla hepática ocurrieron en 21 (88%) de los 24 pacientes del grupo de falla hepática, diferencia que es significativa (p 〈 0.001). Con base en estos datos hacemos las siguientes recomendaciones: (a) se debe realizar un examen histológico antes de emprender la resección, (b) la pérdida perioperatoria de sangre debe limitarse a menos de 2,000 g, (c) el cuidado intensivo postoperatorio es necesario para prévenir complicaciones que puedan dar lugar a falla hepática.
    Notes: Abstract To study the causes of postoperative hepatic failure in cirrhotic patients undergoing resection for hepatocellular carcinoma, we evaluated data on 126 cirrhotic patients surgically treated from 1977 to 1987. The records of 102 patients with a good postoperative course (survival group) and 24 patients who developed hepatic failure and died (hepatic failure group) were reviewed. No difference in preoperative liver function was apparent between the 2 groups. Histologically, moderate to severe inflammatory activity in the liver was present in 20 (83%) of 24 patients in the hepatic failure group. Major hepatic resections (lobectomy and extended lobectomy) were more frequent in the hepatic failure group. Mean perioperative blood loss was 1,945 g and 4,322 g in the survival and hepatic failure groups, respectively, with a significant difference (p 〈 0.01). Major postoperative complications occurred in 22 (22%) of 102 patients in the survival group and major complications followed by hepatic failure occurred in 21 (88%) of 24 patients in the hepatic failure group, with a significant difference (p 〈 0.001). In light of these data, we propose that: (a) histological examination should be done before the resection, (b) perioperative blood loss should be less than 2,000 g, and (c) intensive care is needed postoperatively to prevent complications which might lead to hepatic failure.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF01670561
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  • 8
    Electronic Resource
    Electronic Resource
    Minute liver cancer and concomitant esophageal varices: Detection and successful surgical treatment (1981)
    Springer
    World journal of surgery 5 (1981), S. 707-711 
    Details
    ISSN: 1432-2323
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Résumé Le traitement du cancer du foie associé à des varices oesophagiennes fut pratiqué chez 8 cirrhotiques qui présentaient une hypertension portale. Chez 5 malades, admis pour le traitement chirurgical de varices oesophagiennes, un cancer limité du foie fut décelé au moment de l'exploration opératoire. Chez 3 malades le diagnostic d'hépatome avait été porté avant l'intervention. L'exérèse de la tumeur du foie suivie d'une anastomose porto-cave fut pratiquée avec succès chez 6 malades. Le traitement simultané des varices oesophagiennes et du cancer du foie est possible quand la tumeur hépatique est découverte à un stade précoce. Le procédé le plus fiable pour aboutir à un diagnostic exact est représenté par l'artériographie hépatique. Notre propre expérience nous incite donc à recommander l'étude artériographique chez les cirrhotiques, particulièrement quand on envisage de traiter chirurgicalement les varices oesophagiennes.
    Notes: Abstract Surgical treatment of liver cancer associated with esophageal varices was carried out in 8 cirrhotic patients with evidence of portal hypertension. In 5 patients admitted for elective surgery of esophageal varices, minute hepatomas were detected during the course of preoperative investigation. The remaining 3 patients were referred to our department when esophageal varices plus hepatoma had become evident. Extirpative treatment of the liver tumor followed by selective shunt operations were successfully carried out in 6 patients, and interrupted procedures were used in 2 patients. Treatment of both esophageal varices and liver cancer appears to be effective when the tumor in the liver is detected in an early stage. The most reliable diagnostic tool at the present time seems to be hepatic arteriography. Our experience strongly suggests that arteriographic studies should be seriously considered in cirrhotic patients, particularly when surgery for varices is being contemplated.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF01657932
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  • 9
    Electronic Resource
    Electronic Resource
    Book review (1995)
    Springer
    Surgery today 25 (1995), S. 1000-1000 
    Details
    ISSN: 1436-2813
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF00312395
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  • 10
    Electronic Resource
    Electronic Resource
    Hepatocyte-based Bioartificial Liver Support: Past, Present and Future (1998)
    Springer
    Surgery today 28 (1998), S. 483-486 
    Details
    ISSN: 1436-2813
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s005950050170
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