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PubMed2006

Increase in numbers of beta-lactam-resistant invasive Streptococcus pneumoniae in Brazil and the impact of conjugate vaccine coverage.

A comprehensive investigation of invasive Streptococcus pneumoniae was carried out in Brazil as part of the programme of the national epidemiological surveillance system. The investigation provided data on the trends of resistance to antimicrobial agents. A total of 6470 isolates of S. pneumoniae collected in the country from 1993 to 2004 were tested. During this period of time, the number of penicillin-resistant strains rose from 10.2 to 27.9%. The proportions of intermediate and high-level resistant strains in 1993, which were 9.1 and 1.1%, respectively, rose to 22.0 and 5.9% in 2004. Geometric mean MICs for penicillin increased after the year 2000, to 0.19 microg ml(-1) in 2004; most of these isolates were from patients with pneumonia and from children under 5 years old, and belonged to serotype 14. There was a significant increase in the number of isolates belonging to serotypes included in the 7-valent conjugate vaccine from children under 5 years old: from 48.6% in 1993 to 69.6% in 2004, mainly related to an increase in the frequency of serotype 14 isolates. From 2000 to 2004, meningitis isolates showed higher resistance rates to cefotaxime (2.6%) compared to non-meningitis isolates (0.7%); percentages of isolates resistant to trimethoprim-sulfamethoxazole, tetracycline, erythromycin, chloramphenicol and rifampicin were 65, 14.6, 6.2, 1.3 and 0.7 %, respectively. No levoflaxin resistance was observed. Multidrug resistance was identified in 4.6% of isolates, of which 3.8% were resistant to three classes, 0.7% to four classes and 0.1% to five classes of antimicrobial agent. The study provides valuable information that may support empirical antimicrobial therapy for severe S. pneumoniae infections in Brazil, and emphasizes the need for conjugate pneumococcal vaccination.

Adolescent↗
PubMed2006

Molecular typing and virulence markers of Yersinia enterocolitica strains from human, animal and food origins isolated between 1968 and 2000 in Brazil.

Molecular typing and virulence markers were used to evaluate the genetic profiles and virulence potential of 106 Yersinia enterocolitica strains. Of these strains, 71 were bio-serotype 4/O : 3, isolated from human and animal clinical material, and 35 were of biotype 1A or 2 and of diverse serotypes, isolated from food in Brazil between 1968 and 2000. Drug resistance was also investigated. All the strains were resistant to three or more drugs. The isolates showed a virulence-related phenotype in the aesculin, pyrazinamidase and salicin tests, except for the food isolates, only two of which were positive for these tests. For the other phenotypic virulence determinants (autoagglutination, Ca(++) dependence and Congo red absorption), the strains showed a diverse behaviour. The inv, ail and ystA genes were detected in all human and animal strains, while all the food isolates were positive for inv, and 3 % of them positive for ail and ystA. The presence of virF was variable in the three groups of strains. The strains were better discriminated by PFGE than by enterobacterial repetitive intergenic consensus PCR (ERIC-PCR). A higher genomic similarity was observed among the 4/O : 3 strains, isolated from human and animal isolates, than among the food strains, with the exception of two food strains possessing the virulence genes and grouped close to the 4/O : 3 strains by ERIC-PCR. Unusually, the results revealed the virulence potential of a bio-serotype 1A/O : 10 strain, suggesting that food contaminated with Y. enterocolitica biotype 1A may cause infection. This also suggests that ERIC-PCR may be used as a tool to reveal clues about the virulence potential of Y. enterocolitica strains. Furthermore, the results also support the hypothesis that animals may act as reservoirs of Y. enterocolitica for human infections in Brazil, an epidemiological aspect that has not been investigated in this country, confirming data from other parts of the world.

Agglutination Tests↗
PubMed2006

Tomato yellow spot virus, a tomato-infecting begomovirus from Brazil with a closer relationship to viruses from Sida sp., forms pseudorecombinants with begomoviruses from tomato but not from Sida.

Geminiviruses are characterized by a circular, single-stranded DNA genome and twinned icosahedral particles. Begomoviruses (whitefly-transmitted geminiviruses) are a major constraint to crop production worldwide. In Brazil, tomato-infecting begomoviruses emerged as serious pathogens over the last 10 years, due to the introduction of a new biotype of the insect vector. Tomato yellow spot virus (ToYSV) is a newly described begomovirus originally isolated from tomato, but phylogenetically closer to viruses from Sida sp. A study was performed to determine the viability of pseudorecombinants formed between the DNA components of ToYSV and other weed- and tomato-infecting begomoviruses from Brazil. Despite its closer relationship to weed-infecting viruses, ToYSV was only capable of forming viable pseudorecombinants with tomato viruses. An infectious pseudorecombinant formed between ToYSV DNA-A and tomato crinkle leaf yellows virus (TCrLYV) DNA-B induced severe symptoms in Nicotiana benthamiana. This was attributed, at least in part, to the fact that the origins of replication of both components had identical Rep-binding sequences. However, this was not the case for another infectious pseudorecombinant formed between tomato golden mosaic virus (TGMV) DNA-A and ToYSV DNA-B, which have different Rep-binding sequences. These results reinforce the notion that pseudorecombinant formation cannot be explained solely on the basis of phylogenetic relationships and conserved iteron sequences, and suggest that the TGMV Rep protein may be more versatile in terms of recognizing heterologous DNA components than that of ToYSV.

Amino Acid Sequence↗
PubMed1995

Developing an information system to support the pursuit of decentralization. The perspective of Cearà State in Brazil.

Discusses the national health information system in Brazil which, until very recently, consisted of two main structures of health services with a dichotomy between curative and preventive health care acting in a vertical manner. The autonomy of health authorities and specialized structures created numerous independent health information systems with different methods of data collection. Although the issues of decentralization and a unified health system had been agreed on in 1963, they had not been implemented until the new health policy reform was lunched in 1988. The reform was based on the strengthening of primary health care at national level and accelerating decentralization of health systems. However, in spite of strong political will the new health managers at local level are lacking essential information, data and instruments that only a decentralized health management information system can provide. Based on a study conducted in the Cearà State of the north east of Brazil, explores how the present health information system can support the process of decentralization.

Brazil↗
PubMed2004

Inter-hospital dissemination of glycopeptide-resistant Enterococcus faecalis in Brazil.

The antimicrobial susceptibility patterns of 73 glycopeptide-resistant Enterococcus faecalis isolates from nine hospitals in Brazil were analysed by the disk diffusion method and Etests. Isolates were typed by pulsed-field gel electrophoresis (PFGE), and vancomycin resistance genes were detected by PCR. The isolates shared a single major PFGE pattern, with six subtypes, and all were positive for vanA. These results indicate the occurrence of inter-hospital dissemination of glycopeptide-resistant E. faecalis in São Paulo, and raise concerns about the rapid dissemination of this pathogen throughout Brazil.

Anti-Bacterial Agents↗
PubMed1999

Serum n-3 fatty acids, fish consumption and cancer mortality in six Japanese populations in Japan and Brazil.

Japanese people consume significant amounts of long chain n-3 polyunsaturated fatty acids (PUFAs) derived from fish, but the association of PUFAs with cancer mortality has not been fully investigated. To study geographic differences in n-3 PUFAs intake, we compared serum fatty acid and dietary fish intake among various Japanese populations having different rates of cancer mortality. The subjects were 50 men from each of five regions in Japan and 47 Japanese men from Sao Paulo, Brazil. All were randomly selected and aged 40 to 49 years. Serum fatty acids were measured by gas chromatography and the frequency of fish intake was obtained by a food frequency questionnaire. Significant geographic differences in serum fatty acid levels (% of total fatty acids) and fish intake (days/4 weeks) were observed. The percentages of serum total PUFA were similar in the six regions, though there was an almost three-fold difference in n-3 PUFAs content between Brazil (3.9%) and Akita (10.9%). The frequency of total fish intake corresponded to serum n-3 PUFAs composition. The relationship between cancer mortality and serum n-3 PUFAs levels was not clear, though an inverse association between prostate cancer and serum n-3 PUFAs levels appeared to exist. The results suggest that although serum n-3 PUFAs varied significantly, the observed geographic difference did not account for the different cancer risks at the population level.

Adult↗
PubMed1991

Exposure and sensitization to dust mite allergens among asthmatic children in São Paulo, Brazil.

A group of 20 mite allergic asthmatic children aged 6-12 years old, living in São Paulo, Brazil, was studied regarding their degree of sensitization to house dust mites and exposure to mite allergens in their homes. In 18 out of 20 houses at least one dust sample was obtained which contained greater than 10 micrograms Der p I/g of dust. The highest levels of Dermatophagoides pteronyssinus allergens, Der p I and Group II, were measured in bedding samples (geometric mean 38.4 and 36.6 micrograms/g, respectively), followed by bedroom floor, TV room and kitchen. Mite allergen levels in Brazilian houses were as high as those reported to be associated with sensitization and acute attacks of asthma in other parts of the world. In keeping with previous reports that D. farinae is rarely found in Brazil, Der f I was undetectable or found in very low levels (less than 0.5 micrograms/g). Levels of cat allergen Fel d I of greater than 8 micrograms/g of dust were obtained only in 2 houses only. Cockroach allergen Bla g I was detected in five out of 20 houses. Levels of IgE antibodies to D. pteronyssinus were greater than 200 RAST U/ml in 19 out of 20 children (geometric mean 1588 RAST U/ml). IgE antibodies to cat, cockroach, A. fumigatus, ragweed and rye grass pollens were undetectable or less than 80 RAST U/ml. IgE antibodies to the mite Blomia tropicalis were also measured, and levels greater than 200 RAST U/ml were observed in 13 out of 20 sera.(ABSTRACT TRUNCATED AT 250 WORDS)

Allergens↗
PubMed2004

International educational partnership for practice: Brazil and the United Kingdom.

BACKGROUND: To enhance healthcare globally, successful academic partnerships between institutes of higher education are crucial to strengthen collaboration between countries and identify new ways of working. The desire to reduce maternal mortality and morbidity among childbearing women in north-east Brazil urged professional nurses to seek new ways of working through such a partnership. Reflections on the success of the link identify the key qualities uniting the partnership. AIMS: This paper explores the key qualities of a higher education partnership between the United Kingdom and north-east Brazil. These qualities can act as a guide to other faculties engaged in such links to facilitate successful collaborative working for gains on both sides. RESULTS: Critical reflections from both partners revealed that the key qualities identified are effective communication, deep commitment and the need for both partners to understand each other's context of care. CONCLUSIONS: Examination of each of these qualities illustrates that the shared perspectives, mutual respect and enriched educational experience are valuable and essential to successful partnership working. This critical reflection illustrates the process of success and how others can benefit from the lessons learned, whatever the nature of partnership. Understanding the nature of collaborative working has strengthened each education and practice community, encouraged them to take risks, and remain committed to collective success.

Brazil↗
PubMed2005

Transforming the obstetric nursing workforce in NE Brazil through international collaboration.

AIMS: This paper seeks to analyse the content, people and process of transformational change to introduce new ways of working for specialized obstetric nurses in northeast Brazil, and identify the lessons learned. BACKGROUND: Countries across the globe are beginning to focus on improving the nursing workforce through new ways of working. High numbers of caesarean sections coupled with high indices of maternal mortality in northeast Brazil prompted the introduction of a British Council Higher Education Links scheme to work collaboratively to transform the role of the specialist obstetric nurse and introduce the principles of Safe Motherhood. The concept of a normal birth had not been widely accepted, with the birth process viewed as a medical condition requiring pharmaco-therapeutic interventions rather than as a natural process. METHOD: Between 2000 and 2003, a more woman-centred approach to childbirth was introduced through the local delivery of two in-house education programmes and the qualification of 38 nurse-midwives. DISCUSSION: In spite of its slow progress, the success of the Higher Education collaboration has been recognized nationally, a new philosophy is guiding practice and new ways of working have been established. CONCLUSION: Lessons learned include the need to set achievable goals (content), respond to the emotional needs of those involved in the change (people) and make best use of reciprocal visits to rally the teams and sustain the focus for change (process). Although the Higher Education link is complete, funds are being sought for formal evaluation and dissemination. Overall, the process and outcomes of this collaboration suggest that to embrace such an opportunity to learn from each other can lead to real improvements in service and the lives of women.

Attitude of Health Personnel↗
PubMed2004

The incidence of Shiga toxin-producing Escherichia coli in cattle with mastitis in Brazil.

AIMS: To determine the prevalence and molecular characteristics of Shiga toxin-producing Escherichia coli (STEC) isolates from bovine mastitic milk in Brazil. METHODS AND RESULTS: A total of 2144 milk samples from dairy cattle showing mastitis were screened for the presence of E. coli. A total of 182 E. coli isolates were selected and examined. All were subjected to dot blot analysis using the CVD419 probe for the detection of the enterohaemolysin (hly) gene, and to a multiplex PCR for the detection of stx1, stx2 and eaeA genes. STEC were isolated from 22 (12.08%) milk samples. All the STEC isolates were tested for sensibility to 10 antimicrobials; the resistances most commonly observed were to cephalothin (86.3%), tetracycline (63.6%) and doxycycline (63.6%). CONCLUSION: STEC isolates were found in bovine mastitic milk in Brazil. SIGNIFICANCE AND IMPACT OF THE STUDY: STEC isolates from mastitic milk were potentially pathogenic for human in that they belonged to serogroups associated with diarrhoea and haemolytic-uraemic syndrome, some of them were stx2, eaeA and hly positive.

Adhesins, Bacterial↗
PubMed2005

Phenotypical and molecular characterization of Microsporum canis strains in north-east Brazil.

AIMS: This study investigated the possible correlation between the phenotypical and genotypical characteristics of Microsporum canis isolated from cats and dogs in north-east Brazil. METHODS AND RESULTS: The mycological study was conducted by direct microscopic examination and by fungal culture. Polymerase chain reaction-restriction enzyme analysis and random amplification of polymorphic DNA techniques were used for the genotypical analysis. The morphological analysis showed a considerable diversity of colonies as well as different morphologies of conidia, despite the M. canis strains having been isolated under the same conditions. However, the molecular analysis showed that all analysed strains are genetically similar. CONCLUSIONS: This study, based on phenotypical and molecular analysis, evidences the wide spectrum of phenotypical variations in M. canis in contrast to the stable genotypes of such dermatophytes. SIGNIFICANCE AND IMPACT OF THE STUDY: The findings of this study indicate that M. canis isolated from cats and dogs with dermatophytosis in north-east Brazil may be clones, well adapted to the conditions of this region, despite M. canis showing different morphological features.

Animals↗
PubMed1992

Host preferences of the phlebotomine sandfly Lutzomyia longipalpis in Amazonian Brazil.

Experiments were undertaken to determine the relative attractiveness of humans, dogs and chickens to Lutzomyia longipalpis, the principal vector of Leishmania chagasi causing American visceral leishmaniasis. Field experiments in two villages on Marajó Island, Pará State, Brazil, showed that one boy attracted significantly more flies than one dog or chicken, and slightly fewer flies than a group of six chickens. Experiments with laboratory-bred female flies showed that a significantly greater number of flies engorged on a single human than on either a single dog or chicken, and man-biting catches demonstrated the willingness of flies to bite in the field. It appears that Lu.longipalpis has catholic feeding habits, the attractiveness of different hosts being largely a function of their relative sizes. These results are discussed with reference to the epidemiology of visceral leishmaniasis in Brazil.

Adolescent↗
PubMed2004

Tinea capitis in a dermatology center in the city of Fortaleza, Brazil: the role of Trichophyton tonsurans.

BACKGROUND: Over a 3-year period (March 1999 to March 2002), 944 patients with scalp lesions attended a dermatology reference center in the city of Fortaleza, Ceará, Brazil. Clinical specimens were examined at the Specialized Medical Mycology Center, Federal University of Ceará, Fortaleza-CE, Brazil, to detect patients with tinea capitis. METHODS: Specimens were obtained from pus, scales, and hairs from suspected lesions of tinea capitis. Mycologic analyses were conducted by direct microscopy and by fungal culture on Sabouraud dextrose agar, with or without chloramphenicol and Mycosel agar. The culture tubes were incubated at 28 degrees C and examined daily for 1 month. RESULTS: Fungi were seen in 438 (46.4%) of the 944 clinical specimens. The percentage of positive direct microscopic examinations of the clinical specimens was 83.7%. Of those patients with tinea capitis, 157 (35.8%) were males and 281 (64.2%; P < 0.001) were females. The distribution of dermatophyte species in males, from 136 positive cultures, was Trichophyton tonsurans (54.41%), Microsporum canis (38.97%), T. rubrum (4.41%), T. mentagrophytes var. mentagrophytes (1.47%), and M. gypseum (0.74%). On the other hand, only three species, from 251 positive cultures, were present in females: T. tonsurans (80.08%), M. canis (17.53%), and T. rubrum (2.39%). There was a high proportion of positive results in children under 10 years of age (n = 309). No significant difference was detected in the seasonal distribution of tinea capitis. CONCLUSIONS: Our data show that T. tonsurans is the main etiologic agent of tinea capitis, and is more likely to be found in females and in the prepubertal population.

Adolescent↗
PubMed2004

Epidemiology of Kaposi's sarcoma in patients with acquired immunodeficiency syndrome in São Paulo, Brazil.

BACKGROUND: Kaposi's sarcoma (KS) is the most frequent neoplasm in patients with acquired immunodeficiency syndrome (AIDS). Although many studies on KS epidemiology have been performed in other countries, few have been carried out in Brazil despite the high incidence of AIDS. METHODS: One hundred and seven KS patients seen in São Paulo, Brazil, between August 1995 and November 1998 were studied. The patients were followed for 1 year with assessment of the immunologic status, improvement of the lesions, treatment, and causes of death at the end of this period. RESULTS: KS occurred mainly in men (94.4%) with a mean age of 37 years, and 25.2% of these patients were found to be human immunodeficiency virus (HIV) seropositive through KS. HIV was acquired mainly through homosexual contact. The patients presented an average of 15.9 KS lesions at the first visit and the mean duration of KS lesions before the first visit was 15.5 months. The clinical presentation was predominantly papules and plaques, and 33.6% presented with mucosal and/or visceral disease. KS affected mainly the lower limbs. The mean time since the diagnosis of HIV infection was 42.4 months. The CD4+ cell count was lower than 200 cell/mm(3) in 60.8% of patients, but patients with a complete response showed an improvement in immune status after 1 year. Patients who did not show progression received a protease inhibitor as part of highly active antiretroviral therapy (HAART). Patients treated exclusively with HAART presented a complete response (61.6%), partial response (23%) or progression (15.4%) of KS. CONCLUSIONS: An improvement in immune status and the use of HAART were the most important prognostic features.

Acquired Immunodeficiency Syndrome↗
PubMed2006

Seroprevalence of HHV-8 infection in the pediatric population of two university hospitals in Rio de Janeiro, Brazil.

BACKGROUND: The authors present a serologic survey of the prevalence of herpesvirus-8 (HHV-8) among 171 children from 0 to 12 years old in Rio de Janeiro, Brazil. MATERIALS AND METHODS: Sera were tested for latent nuclear and lytic antigens using indirect immunofluorescence and Western blotting. RESULTS: Serology for HHV-8 was positive in 16 of 171 patients (9.35%). Among 13 HIV-positive patients, four (31%) were also positive for HHV-8. The seropositivity among healthy children was 7.6%, and females were significantly (P<0.002) more associated with HHV-8 seropositivity (16%) than males (1.1%). CONCLUSIONS: We detected a higher HHV-8 seroprevalence among the pediatric population in Rio de Janeiro, Brazil, when compared with similar studies performed in other countries. Nonsexual routes of transmission are a possible explanation for this pattern. The unusual finding of a higher seroprevalence among female children could be explained by a specific route of exposition or even an epidemiological bias.

Brazil↗
PubMedDate not supplied

Survey of bacterial microorganisms in the conjunctival sac of clinically normal dogs and dogs with ulcerative keratitis in Fortaleza, Ceará, Brazil.

OBJECTIVE: The ocular microflora in dogs has not been established in north-east Brazil. Thus, the main aim of this research was to determine the bacterial microorganisms in the conjunctival sac of clinically normal dogs and dogs with ulcerative keratitis in Fortaleza, Ceará, Brazil. ANIMALS STUDIED: This study included 60 healthy dogs, 15 dogs with unilateral corneal ulcer, and three dogs with bilateral corneal ulcers. Procedure Samples were taken by a calibrated platinum loop (1 microL) placed directly onto the conjunctival sac and on sterile blood agar. The clinical specimens were incubated at 37 degrees C in an atmosphere of 5% CO2 for 48 h. RESULTS: Of the 120 samples from healthy dogs, only 47 (39%) had positive culture for bacteria, while all of the specimens from eyes with corneal ulcer were positive for bacterial growth. The group of dogs with corneal ulcer had a higher (P < 0.05) number of colony-forming units (CFU) per plate than the group of healthy animals. Of the 59 isolates from healthy eyes, only nine (15.3%) had more than 50 CFU per plate, while in the group of dogs with corneal ulcer, 23 (62.2%) of the 37 isolates presented more than 50 CFU per plate. In both groups Gram-positive bacteria (86.5%) predominated over Gram-negative (13.5%). Staphylococcus spp. was the most frequently isolated genus and S. intermedius predominated in both groups. CONCLUSION: The results of our study are directly applicable to initiate rational, preventive and therapeutic measures with greater accuracy in dogs with corneal ulcer.

Animals↗
PubMed2005

The G1888A variant in the mitochondrial 16S rRNA gene may be associated with Type 2 diabetes in Caucasian-Brazilian patients from southern Brazil.

AIM: To compare the frequencies of the G1888A variant in the mitochondrial 16S rRNA gene between patients with Type 2 diabetes and non-diabetic control subjects from southern Brazil. METHODS: We analysed 520 Type 2 diabetic patients (389 Caucasian- and 131 African-Brazilians) and 530 control subjects (400 Caucasian- and 130 African-Brazilians). DNA samples were amplified by polymerase chain reaction and digested with the RsaI enzyme. Variant frequency in patients and control subjects was compared using chi2 test, Fisher's exact test or odds ratio test. We also investigated the frequency of the G1888A variant in a subgroup of the patients with a maternal history of Type 2 diabetes plus two or more features of maternally inherited diabetes and deafness. RESULTS: The 1888A allele does not seem to be associated with Type 2 diabetes in African-Brazilians (frequency of 3.8% in patients and 0.8% in control subjects; PFisher=0.213). However, in Caucasian-Brazilians, the 1888A allele was significantly associated with diabetes (12.3% in patients vs. 3.5% in control subjects; OR=3.881; 95% CI 2.106-7.164; P<0.001) and also with higher levels of insulin resistance. The majority of the patients carrying the 1888A allele did not have clinical features of maternally inherited diabetes and deafness. CONCLUSION: The present study indicates the association of the mitochondrial G1888A variant with Type 2 diabetes and insulin resistance in Caucasian-Brazilian patients from southern Brazil. However, further studies are required to confirm its effects on mitochondrial function and the role of these effects on the pathogenesis of Type 2 diabetes.

Aged↗
PubMedDate not supplied

Interventional nephrology in Brazil: current and future status.

The care of chronic kidney disease patients frequently involves many diagnostic and interventional procedures. Most of these procedures are currently performed by radiologists, vascular surgeons, and general surgeons. This has caused fragmented medical care, which has led many nephrologists to introduce a new paradigm, often referred as interventional nephrology (IN). The aim of this study was to establish the extent of involvement of the Brazilian nephrology community with regard to specific IN procedures. From October 2004 to February 2005, questionnaires were sent by e-mail to all 2500 nephrologists throughout Brazil. The enrollment questionnaire was composed of five sections, with questions about renal biopsy, specific training in ultrasonography, peritoneal dialysis access (insertion of peritoneal catheters guided or not by peritoneoscopy), hemodialysis vascular access (ability to place tunneled catheters, construction of arteriovenous fistulas, and other vascular access procedures), and the nephrologist's interest in being trained in IN. A total of 239 nephrologists answered the questionnaire. Only 18% of Brazilian nephrologists perform kidney biopsy guided by ultrasonography assisted by a radiologist. On the other hand, 42% of them reported that this procedure was done without any image support. Most of the respondents (85%) indicated that they were not formally trained to perform renal ultrasonography. When asked about peritoneal dialysis catheter placement, 66% of the respondents reported that they referred their patients to a surgeon for this procedure. The insertion of peritoneal dialysis catheters guided by peritoneoscopy was reported by 3% of the respondents. Similar to the results for peritoneal dialysis catheter placement, the majority of the respondents (77%) indicated no training in the insertion of tunneled catheters for temporary hemodialysis. Regarding the interest of nephrologists to participate in an IN program, the great majority (87%) responded that they would like to be trained in these procedures. Most nephrologists are not trained in IN procedures. Therefore, in Brazil, it will be necessary to develop training centers for IN that will allow nephrologists to optimize nephrology care.

Arteriovenous Shunt, Surgical↗