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20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017
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Image courtesy of Dr. Lars Grimm.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
The above radiograph reveals a Salter-Harris type IV fracture (arrows), which involves the epiphysis, physis, and metaphysis.
In 2015, 40% of children aged 6-12 years regularly played team sports.[1] In 2012, 1.35 million children were seen in emergency departments for injuries related to sports.[2] The most common sport- and recreation-related injuries are sprains and strains, bone and growth plate injuries, repetitive motion injuries, heat-related illness, and concussions.[3,4] Other conditions of concern include cardiopulmonary disorders, infections, and exposure to certain insect species. Do you know which sports and recreational injuries are the most common in your pediatric patients and how to treat them?
Image from Wikimedia Commons | Boldie.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Ankle Sprains
Sprains and strains are the most common childhood sports injuries, with ankle sprains being the most frequent.[4] About 85% of ankle sprains result when running on an uneven surface causes inversion injuries that damage the lateral ligaments.[5] The Ottawa ankle rules and other decision rules may be used to assess whether radiographs are needed in adolescents requiring evaluation for ankle injury.[5] (In elementary- and middle school–aged children, growth plate injuries are more common than ligament injuries.[6]) A comparison between the contralateral foot/ankle for symmetry, deformity, ecchymosis (arrow), edema, tenderness, or crepitus in the physical examination should be included. Treatment to improve range of motion and strength of the ankle is as essential as the reduction of pain.[5] The mnemonics "RICE" (rest, ice, compression, elevation) and "PRICES" (protection, relative rest, ice, compression, elevation, support) describe conservative therapy for acute ankle sprains. Protective devices include air splints and plastic or Velcro braces. Ankle taping can also increase stability, but its effectiveness is highly dependent on the skill of the person doing the taping.[5]
Information sources for the table: McKee,[7] Stracciolini et al,[8] and Nakaniida et al.[9]
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Fractures
The epidemiology of pediatric fractures differs from that of adult fractures, and the risk for fracture increases with age.[6-8,10] Trauma from sports injuries accounts for the majority of pediatric fractures, with the frequency of such injuries being greater in boys than in girls.[8] The most common fracture locations in children are the upper extremities.[9] There is also a growing body of evidence regarding the association between the increasing incidence of obesity in children and greater fracture risk.[11-13]
The top 10 sports that cause the greatest number of injuries in children aged 19 years and younger are football, basketball, soccer, baseball, softball, wrestling, cheerleading, volleyball, gymnastics, and track and field.[14]
Image courtesy of Dr. Lars Grimm.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
The radiograph shown reveals a displaced (arrows) distal femur fracture (Salter-Harris type 2) in a 16-year-old boy after a fall.
Pediatric patients are at risk for a specific set of fractures. The increased bone flexibility, decreased bone density, proportionally stronger ligaments and tendons, and developing growth plates in these patients lead to unique fracture patterns that may require specific treatment options.[6,8,10]
In one study, the most common injuries that required inpatient care were femur and humerus fractures; injuries associated with the highest costs were vertebral and pelvic injuries, primarily caused by motor vehicle accidents (MVAs).[9]
Images courtesy of Radiopaedia | Dr. Matt Skalski.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Salter-Harris fractures
Fractures through a growth plate, which are unique to pediatric patients, are classified as Salter-Harris fractures (shown above).[15] The mnemonics "SALTR" and "SMACK" can be used to help remember the five most common Salter-Harris fracture types.[16,17] These mnemonics require the reader to imagine the bones as long bones, with the epiphyses at the base.
The SALTER mnemonic consists of the following[16,17]:
Type I - S = Slipped or straight across; fracture of the cartilage of the physis (growth plate)
Type II - A = Above; this is the most common type of Salter-Harris fracture;[15] the fracture lies above the physis
Type III - L = Lower; the fracture is below the physis, in the epiphysis
Type IV - T = Transverse or through or together; the fracture is through the metaphysis, physis, and epiphysis
Type V - R = Ruined or rammed (crushed); the physis has been crushed
The SMACK mnemonic is as follows[16]: S = slipped (type I); M = metaphyseal (type II); A = articular (epiphyseal) (type III); C = complete (metaphysis and epiphysis) (type IV); and K = krushed! (type V).
Image courtesy of Dr. Lars Grimm.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
The above radiograph reveals a Salter-Harris type IV fracture (arrows) of the proximal tibia in a 13-year-old boy. The fracture involves the epiphysis, physis, and metaphysis.
Similar to a type III fracture, a type IV fracture is an intra-articular injury and can result in chronic disability. It can also, through interference with the growing layer of cartilage cells, cause deformity of the joint.[15] Management of physeal fractures depends on the severity, site, classification, and plane of the injury, as well as the patient's age and the growth potential of the affected physis.[6,18] In general, type I and II injuries can be treated with careful closed reduction and casting or splinting, followed by reexamination in 7-10 days to assess maintenance of the reduction. More severe injuries, involving intra-articular fractures (types III and IV), typically require anatomic reduction with open reduction and internal fixation that avoids crossing the physis.[6,18] Treatment for type V fractures often involves cast immobilization; surgical intervention may be needed to restore bone alignment.[18]
Image courtesy of Dr. Lars Grimm.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Stress fractures
The image demonstrates an increased T2 signal (arrow) in the third metatarsal due to a stress fracture in a 16-year-old who had normal radiographs of the foot.
Stress fractures (structural failure and fracture caused by repeated stress to the bone) and tendinopathy can result from repetitive motion and the overuse of muscles and tendons.[19-21] Stress fractures can develop from excessive exercise, increase in exercise, poor mechanics, weak musculature, and hormonal deficits. Stress fractures are often not visible on radiographs, but they can cause significant discomfort.[4] Magnetic resonance imaging (MRI) is the most sensitive test for the detection of stress injuries. These injuries usually respond to relative rest, and ice and elevation can reduce pain. Treatments may also include immobilization with a splint or cast, crutches, and physical therapy to correct the mechanics that caused the abnormal stress.[4]
Image courtesy of Dr. Lars Grimm.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Incomplete fractures
The image reveals a minimally displaced greenstick fracture (arrow) of the distal radius in a 9-year-old boy.
Incomplete fractures, such as the greenstick, bow, and torus (or buckle) types, are common childhood injuries.[22-24] Younger children have softer bones with relatively more collagen, that are less fragile than those of adults.[22,25] The softer bone bends and only partially breaks; thus, one side may buckle upon itself without disrupting the other side. Greenstick fractures occur when a bone, fractured on one side, bends inward, but does not fracture, on the other side. Bow fractures occur when the bone becomes curved along its longitudinal axis as a result of longitudinal forces. Torus fractures are caused by impaction.[22-24] Incomplete fractures are generally treated with external immobilization; if a severe deformity is present, creation of a complete fracture may be necessary.[22,25]
Image courtesy of Dr. Lars Grimm.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Hand and wrist fractures
The above radiograph demonstrates an ulnar styloid fracture (red arrow) and a buckle fracture of the distal radius (yellow arrow), in a 12-year-old girl.
Sports injuries of the hand and wrist are common. Delayed diagnosis and treatment of hand injuries can lead to significant morbidity because the avoidance of many long-term complications is dependent on timely intervention. Although most injuries can be treated by an emergency department provider, it is important to understand the diagnostic and therapeutic options so that patients can be triaged appropriately.
Images from Medscape.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Pinckney and Seymour fractures
The fact that the growth plate of the distal phalanx is so close to the nail plate means that when a subungual hematoma (blue arrow) occurs in conjunction with a growth plate fracture (orange arrow), this represents an open fracture.[6] When the injury occurs in the great toe (or at times, lesser toes), it is termed a Pinckney fracture. In the hand, such fractures of the distal phalanx are called Seymour fractures.[6] Open fractures are treated with antibiotics.
Image courtesy of Dr. Lars Grimm.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Clavicular fractures
The radiograph shows a displaced clavicular fracture with foreshortening (dashed line) in a 7-year-old.
Traumatic football injuries to the shoulder can occur despite upper body padding, due to improperly fitted shoulder pads or an impact of excessive force. Clavicular fractures can occur from a fall onto the shoulder or an outstretched hand.[26] The diagnosis is usually clinical but can be confirmed with radiographs, and the overwhelming majority of clavicular fractures can be treated nonoperatively (eg, analgesia, arm support, physical therapy).
Clavicular fractures should prompt consideration of additional injuries, including traction injury to the brachial plexus, which runs from the cervical spinal cord through the upper shoulder and into the axilla.[26] Damage to the brachial plexus may result in loss of sensation or muscle control in the arm, wrist, hand, or fingers.[27] The majority of brachial plexus injuries resolve with nonoperative therapy.
Image courtesy of DermNet New Zealand.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Heat- and Sun-Related Disorders
Preventable heat- and sun-related illnesses include sunburn (shown), heat cramps, heat exhaustion, and heat stroke. A child with sunburn can be made more comfortable with a cool bath or cool compresses; administration of acetaminophen or ibuprofen, to combat fever and discomfort; and application of a topical moisturizer, aloe gel, hydrocortisone cream, or topical pain reliever. Moreover, the child should be kept out of the sun until the burn has healed and should be given extra fluid for several days in order to avoid dehydration. The child's health-care provider should generally be contacted if the youngster's sunburn is severe or forms blisters or if signs and symptoms of heat stress, including fever, chills, nausea, vomiting, dehydration, or a feeling of faintness, occur.[28]
Children sweat less than adults, which makes it more difficult for children to cool off.[4,29] The most common heat-related illness is heat cramps. These intense muscle spasms usually develop after a child has been exercising for a long period of time and has lost large amounts of fluid and salt through sweating.[30,31]
Heat cramps are a mild form of heat illness that can be easily treated. Remove the child from activity, and place him or her in a cool area with no sun exposure. Provide water and food or a sports drink that contains electrolytes to help replace lost fluid and sodium;[30,31] do not give caffeine. Light stretching, relaxation, and ice massage of the cramped muscles may also help.[30]
Image courtesy of Medscape | KE Greer, MD.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
The miliaria pustulosa stage of heat rash is shown above.
Heat rash, often consisting of small, red, pruritic bumps, is caused by blocked sweat glands, which usually result from excessive sweating.[31,32] It appears most often in areas covered by clothing, when the weather is hot and humid. Treatment of heat rash includes keeping the patient out of the sun, placing him or her in a cool area, and keeping the affected area dry.[31,32] These rashes are often self-limited, resolving in a few days.
Heat exhaustion occurs when plasma volume and electrolytes lost through perspiration are not replaced.[31] The major issue is dehydration resulting in weakness, fatigue, dizziness, syncope, nausea, and vomiting. Treatment includes rest, cooling, and fluid and electrolyte replacement.[31]
Image from Medscape.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Heat stroke occurs with elevated body temperature, usually in excess of 40.5°C (104.9°F), with altered sensorium.[33] Anhidrosis may or may not be present. Risk factors for heat stroke are dehydration, fatigue, poor fitness, and lack of acclimatization to the heat.[33] In situations where heat stroke may occur, water should always be available to replace evaporative losses, and much effort has been made to educate coaches about the proper procedures and precautions to follow when teams are practicing or playing in the heat.[34] In cases of heat stroke, immediate cooling is necessary, with cold water immersion being safe and the best choice.[34-37] The equipment needed for noninvasive cooling includes ice, water, and an air-cooling blanket, as shown. More invasive cooling options include nasogastric and peritoneal lavage.
Image from the National Oceanic and Atmospheric Administration (NOAA) National Weather Service.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
The above chart demonstrates the heat index, that is, a measure of how hot the environment feels when relative humidity combines with the actual air temperature.
As humidity rises, the body's ability to radiate heat through the evaporation of sweat diminishes, and the risk for heat-related illness increases. Children should receive a 5- to 10-minute rest and fluid break after every 25-30 minutes of activity as the temperature climbs past 98°F.[34] At this temperature, as the humidity rises past 55%, children should be in shorts and a t-shirt, using only a helmet and shoulder pads if protective equipment is needed. Once the humidity rises past 80%, children should remove all protective equipment during activity.[34] When the temperature is over 98°F and the humidity is 100%, coaches and trainers should cancel or postpone all outdoor practices/games. Practice may instead be held in an air-conditioned space.
Image courtesy of Dr. Lars Grimm.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Traumatic Brain Injuries
The computed tomography (CT) scan shown demonstrates an epidural hematoma (arrow) in a 13-year-old boy involved in a motor vehicle crash.
Traumatic brain injury (TBI) is caused by an insult to the head or body that disrupts the normal function of the brain.[38] Most TBIs are mild (concussions), with the injuries being functional, not structural, and no abnormalities being seen on CT or MRI scan.
An estimated 250,000 children aged 19 years or younger are treated each year for sports and recreation injuries that include a diagnosis of concussion or TBI. Among children aged 14 years or younger, 55% of TBIs are caused by falls, although the leading cause of TBI-related deaths in this age group is MVAs.[38]
Brain contusions may be associated with localized structural damage and bleeding, often from multiple hemorrhages,[39] which are readily apparent on CT scans.[39] They are most commonly found in the frontal and temporal lobes.[40]
Image courtesy of Dr. Lars Grimm.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Brain damage caused by concussions can have long-term effects.[41,42] Although there are many symptoms of concussion, they usually fall into four categories: thinking/remembering, physical, emotional/mood, and sleep. Affected patients may present with a headache, dizziness/unsteadiness, confusion/disorientation, difficulty concentrating, amnesia, blurred or double vision, drowsiness, and/or irritability.[41,42] The diagnosis is clinical, based on a thorough systematic evaluation of the injury and its manifestations, as routine imaging studies of the brain such as CT scanning and MRI (shown) are typically normal.[42] Patient monitoring, rest, and careful management of physical and cognitive exertion are essential for recovery. Refer patients for diagnostic testing or to a concussion specialist for persistent, severe, and/or changing symptoms.[42]
Image from Wikimedia Commons | Agateller.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Commotio Cordis
Commotio cordis is defined as instantaneous cardiac arrest produced by a nonpenetrating blow to the chest that occurs within a specific 10- to 30-ms portion of the cardiac cycle (shown), in the absence of preexisting heart disease or identifiable morphologic injury to the sternum, ribs, chest wall, or heart.[43,44] Commotio cordis occurs only if the blow is struck during the ascending phase of the T wave, when the ventricular myocardium is repolarizing. If the cardiac cycle's duration for an individual were about 1 second on average, the probability of mechanical trauma occurring within the window of vulnerability would be only 1-3%; this small window explains why commotio cordis is such a rare event.
Image from Wikimedia Commons | Gray's Anatomy of the Human Body, 20th US ed.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
The image shows the human adult thorax, with the heart outlined in red. The zone for mechanical induction of heart rhythm disturbances lies between the second and fifth ribs, to the left of the sternum.[44,45]
Despite its overall rarity, commotio cordis is reportedly among the most common causes of sudden cardiac arrest in young US athletes. (Hypertrophic cardiomyopathy [HCM] is the most common cause; much data indicate that congenital coronary anomalies make up the second most common cause). Initial reports in the national registry had overall survival rates for commotio cordis of less than 5%, but more recent survival rates appear to approach 60%.[45] Chest protectors and vests are designed to reduce trauma from blunt bodily injury, but they do not offer absolute protection, considering that about 32% of past commotio cordis victims were wearing chest protectors.[43,45]
Commotio cordis is a diagnosis of exclusion, as other causes of cardiac arrest (eg, myocardial infarction, electrolyte abnormality, long QT syndrome, ventricular fibrillation, HCM) must first be ruled out. Treatment is essentially the same as for other cardiopulmonary emergencies, including prompt recognition, early cardiopulmonary resuscitation, and rapid defibrillation.[43-45]
Image from Wikimedia Commons | BruceBlaus.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Exercise-Induced Bronchospasm
A normal (left) versus inflamed (right) airway is shown above.
Exercise-induced bronchospasm (EIB) (also called exercise-induced asthma) is a bronchospasm that is triggered by the loss of moisture in the airways from an increased respiratory rate or from cooling of the airways as a result of the rapid breathing of air that is lower than body temperature.[46-48] Once the attack is triggered, bronchospasm, edema, and mucus production and plugging can occur.[46,47] Children with asthma often experience symptoms of the disorder during physical activity. However, there are many children without asthma who develop bronchospasm symptoms only during exercise[47,48] or only in specific environments (eg, ice rinks, indoor swimming pools).[47] Children with EIB are thought to be more sensitive to changes in air temperature and humidity. Fortunately, in children with EIB but without asthma, maintenance therapy is often not required, and medication (eg, short-acting bronchodilators) may be needed only before exercise.[46-48]
Image courtesy of DermNet New Zealand.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Tinea Corporis
Tinea corporis (ringworm) is a contagious fungal skin infection (shown) that easily spreads via skin-to-skin contact and shared clothing or equipment.[49] The affected skin is often itchy and scaly. Most cases are easy to treat with antifungal creams. To prevent tinea corporis, children should avoid sharing clothing, sports gear, and towels, and they should wear loose-fitting clothing made of cotton or synthetic materials.[49]
Image courtesy of DermNet New Zealand.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Tinea Pedis
Fungal infection of the foot (tinea pedis), also known as athlete's foot (shown), is an extremely common and easily spread skin disorder.[50] This condition causes scaling and inflammation in the toe webs and results in itching, burning, redness, and stinging on the soles of the feet.[51] Like tinea corporis, tinea pedis can be treated with antifungal creams; in cases of severe or resistant infections, providers may prescribe oral antifungal medicines.[50,51] Tinea pedis is difficult to prevent, but to reduce the risk of infection, children should wear foot protection (eg, sandals) in locker rooms and bathing areas, keep their feet clean and dry, and wear shoes that are well ventilated and made of natural materials.[50,51]
Image from the Centers for Disease Control and Prevention (CDC) | Gregory Moran, MD.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
MRSA Infections
Staphylococcus aureus infections (shown) are an increasing public health concern in pediatric and adolescent populations, particularly methicillin-resistant S aureus (MRSA) infections.[52] Children are at particular risk of developing a skin infection from MRSA if they have an abrasion, cut, or bug bite; attend daycare centers or school settings; or come into contact with others in locker rooms and workout facilities. Shared towels and equipment are a haven for this bacterium.[52]
MRSA is resistant to many antibiotics and often requires specific antibiotic treatment. To prevent an MRSA infection, children should wash their hands often with soap and water for at least 15 seconds or use alcohol-based hand sanitizers/wipes; avoid sharing bar soap, towels, razors, uniforms, and other items that touch the skin; and keep wounds covered.[52,53] Treatment may involve incision and drainage (I&D) of the abscess and/or appropriate antibiotic therapy that is based on local susceptibility rates.
Images from (left) CDC | Gregory Moran, MD; (right) CDC Public Health Image Library (PHIL).
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Athletes competing in contact sports are at increased risk of developing an MRSA infection. In its early stages, an MRSA skin infection is often confused with a rash, pimple, or spider bite, as the symptoms may be similar, with the affected area becoming red, swollen, warm, or tender.[52,53] Over 48 hours, the area frequently becomes more painful and swollen. Often, an abscess (left) will develop under the skin; occasionally, this lesion will begin to drain on its own (right), while at other times, the abscess will require I&D. When cellulitis spreads or does not improve after 2-3 days of treatment with routine antibiotics, it may be MRSA.
Image from Wikipedia | James Heilman, MD.
20 Pediatric Summer Sports and Recreational Injuries to Know
Mark P. Brady, PA-C | August 16, 2017 | Contributor Information
Hymenoptera Stings
The child seen here is suffering from allergic angioedema; the resultant swelling prevents him from opening his eyes.
Sports and recreational activities often take place outdoors, particularly during warm weather, where children may encounter stinging insects from the order Hymenoptera, which includes bees, wasps, yellow jackets, hornets, and ants.[54] Stings from these insects commonly result in swelling and other symptoms, such as redness from the sting or bite that may last a week or more, nausea, fatigue, and low-grade fever. Rarely, stings can result in a life-threatening anaphylactic reaction with difficulty breathing; hives; swelling of the face, throat, or mouth; rapid pulse; or a drop in blood pressure that causes dizziness or unconsciousness.[54,55]
For persons who are severely allergic, epinephrine should be administered immediately after a sting, and the patient should be rapidly transported to the closest appropriate medical facility.[54] The patient's cardiopulmonary status should be monitored. In the absence of a severe allergic reaction, the stinger should be removed and the sting site cleaned.[54,55] Ice may be applied to reduce swelling; oral antihistamines may reduce itching, and ibuprofen or acetaminophen may be used for pain relief.
16 Can't-Miss Findings on Pediatric Imaging Studies
Evaluation of pediatric imaging studies can be challenging for clinicians. Can you correctly identify the abnormal findings in these cases?Slideshows, August 2017
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Contributor Information
Author
Mark P. Brady, PA-C
Department of Emergency Medicine
Emerson Hospital
Concord, MA
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
Assistant Professor
Department of Diagnostic Radiology
Duke University Medical Center
Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
José Luiz de Oliveira Schiavon, MD, MSc
Associate Professor
Department of Pediatric Radiology
Instituto de Oncologia Pediatrica
Universidade Federal De Sao Paulo
Sao Paulo, Brazil
Disclosure: José Luiz de Oliveira Schiavon, MD, MSc, has disclosed no relevant financial relationships.
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