[ARVD-FORUM] Some more remarks. Dr. Perez Riera

Wed Apr 6 13:00:03 ART 2005

English - Portuguese

Dear Bortolo:

The prevalence, incidence and prognostic value of the Brugada-type ECG has
been studied in a general adult Japanese population. The 4,788 subjects
(1,956 men and 2,832 women) were under 50 years of age in 1958 and had
undergone biannual health examinations, including ECG, through 1999. There
were a total of 32 Brugada-type ECG cases. The prevalence and incidence were
146.2 in 100,000 persons and 14.2 persons per 100,000 person-years,
respectively. The incidence was nine times higher among men than women, and
the average age at presentation was 45 +/- 10.5 years. The Brugada-type ECG
appeared intermittently in most cases and was found in 26% of subjects who
died unexpectedly. Cox survival analysis revealed that mortality from
unexpected death was significantly higher in subjects with a Brugada-type
ECG than in control subjects (p < 0.01). Unexpected deaths were more
frequent among subjects with the Brugada-type ECG who had a history of
syncope (p < 0.05). The Brugada-type ECG was found in 0.70% of 13,929 study
subjects (98 cases) in a community-based population in Japan, predominantly
in men. The typical coved-type ST-T morphology with the RBBB pattern-an rsR'
pattern in the V1 lead ("typical" Brugada-type  1)-was found in 0.12% of all
subjects.

The prevalence of cardiac events among male subjects with a Brugada-type ECG
(81%) was significantly higher than it was for those without it.

 The Brugada-type ECG was found in 2.14% of male subjects, and the "typical"
Brugada-type 1 was found in 0.38%. After 2.6 +/- 0.3 years of follow-up,
there was one death of a subject with the Brugada-type ECG, whereas there
were 139 deaths of those without the Brugada-type ECG (p = 0.9943, log-rank
test). The total mortality of subjects with the Brugada-type ECG did not
differ from the mortality of those without the Brugada-type ECG (Miyasaka Y,
Tsuji H, Yamada K, et al. Prevalence and mortality of the Brugada-type
electrocardiogram in one city in Japan.  J Am Coll Cardiol 2001;38:771-774.)

>From about 12,000 non-selected and non-cardiac patients in just one
University Hospital, collected prospectively for a period of two years,
there were 52 cases with the typical ECG pattern, i.e., with Brugada sign
(Monroe MH, Littmann L. Two-year case collection of the Brugada syndrome
electrocardiogram pattern at a large teaching hospital. Clin Cardiol.
2000;23:849-851.)

A report in France have shown a prevalence of Brugada pattern of ECG in 1
per 1,000 normal asymptomatic individuals (Hermida J, Lemoine J, Aoun FB, et
al.: Prevalence of the Brugada syndrome in an apparently healthy population.
Am J Cardiol; 2000; 86:91-94.)

The prevalence, incidence, and prognosis of the Brugada-type ECG were
analyzed in the general population of Japan, based on a study of four
decades. Thus, from a group of 4788 individuals, 32 Brugada-type ECGs were
detected, the prevalence and incidence being 146.2 in 100,000 people and
14.2 per 100,000 individuals/year, respectively. This incidence was nine
times higher in men than in women; the intermittence of the Brugada-type ECG
was found in 26% of cases of those who underwent SCD, and the Cox survival
analysis showed that unexpected mortality was significantly higher in
subjects with the Brugada-type ECG than in control subjects ( Matsuo K,
Akahoshi M, Nakashima E, et al. The prevalence, incidence and prognostic
value of the Brugada-type electrocardiogram: a population-based study of
four decades.  J Am Coll Cardiol 2001; 38:765-770.)

Monroe and Littmann (2000), in 12,000 consecutive ECG in non-cardiac
patients, during two years, they found Brugada pattern in 52 ECGs showing a
higher prevalence than thought before( Monroe MH, Littmann L. Two-year case
collection of the Brugada syndrome electrocardiogram pattern at a large
teaching hospital. Clin Cardiol. 2000; 23:849-851.)

Prevalence and prognosis of subjects with Brugada-type ECG pattern was
studied in 2479 healthy young male Air Force applicants age 18-30 years) and
in 542 healthy middle-aged subjects age between   40-60 years Finnish
population. Fifteen (0.61%) subjects in the first population and three
subjects in the second population (0.55%) fulfilled the ECG criteria for
Type 1 or 2 Brugada syndrome pattern. They had J-point elevation and a
saddleback-type ST-segment configuration in the right precordial leads. Type
1 Brugada ECG pattern (coved ST-segment elevation) was not seen in any
subject. The benign natural course of the patients with the "Brugada sign"
suggests that in asymptomatic subjects without a family history of SCD, Type
2 or 3 Brugada ECG pattern is a normal variant rather than a specific
predictor of life-threatening ventricular arrhythmias (Junttila MJ,
Raatikainen MJ, Karjalainen J, Kauma H, Kesaniemi YA, Huikuri HV. Prevalence
and prognosis of subjects with Brugada-type ECG pattern in a young and
middle-aged Finnish population. Eur Heart J. 2004; 25:874-878.)

The prevalence of typical drug-induced Brugada syndrome ECGs was 5 of the
1,000 patients. This value was fivefold greater than the reported prevalence
of spontaneous Brugada syndrome ECGs in the healthy population (Hermida JS,
Jandaud S, Lemoine JL, Rodriguez-Lafrasse C, Delonca J, Bertrand C, Jarry G,
Rochette J, Rey JL. Prevalence of drug-induced electrocardiographic pattern
of the Brugada syndrome in a healthy population. Am J Cardiol. 2004;
94:230-233.)

Best Regard

Andrés Ricardo Pérez Riera

---------------------------------------

Português

Prezado Bortolo:

A prevalência, incidência e valor prognóstico do padrão ECG Brugada ha sido
estudado na população adulta Japonesa.  De 4.788 pessoas  (1,956 homens e
2,832 women)  estavam abaixo dos 50 anos desde 1958 ate 1999 Se detectaram
um total de 32 ECG tipo Brugada, A prevalência e incidência foi  146.2 em
100.000 pessoas e 14.2 pessoas por 100.000 pessoas-ano respectivamente. A
incidência foi 9 vezes mais alta entre homens do que mulheres e a média de
idade no momento da apresentação foi de 45+/- 10.5 anos. O tipo
eletrocardiográfico  foi intermitente na maioria dos casos e se encontrou
morte inesperada em 26%. Análise Cox de sobrevida revelou que a mortalidade
por MS inesperada foi significativamente mais alta em sujeitos com o padrão
eletrocardiográfico Brugada que no controle ( p<0.01) Mortes inesperadas
foram mais freqüentes entre sujeitos com o padrão eletrocardiográfico
Brugada os quais tinha história de síncope ( p<0.05).

O padrão ECG Brugada foi encontrado em 0.70% de 13,929 pessoas estudadas
(98 casos) numa comunidade japonesa predominantemente em homens.O padrão ECG
tipo 1 coved de ST com BRD foi encontrado em 0.12% de todo o universo.

A prevalência de eventos cardíacos entre homens com o padrão ECG Brugada (81%) 
foi significativamente mais alto que em aqueles sem ele.

A prevalência do tipo ECG Brugada foi encontrado em 2.14% de homens e o tipo
1 se encontrou em 0.38%. Apos  2.6+-0.3 anos de seguimento, se encontrou uma
morte num paciente portador do padrão ECG Brugada apesar que ocorreram 139
mortes entre aqueles sem o padrão ECG Brugada (p = 0.9943, log-rank test).

A mortalidade total de pessoas com o padrão ECG Brugada não foi diferente da
mortalidade de aqueles sem o padrão Eletrocardiográfico Brugada (Miyasaka Y,
Tsuji H, Yamada K, et al. Prevalence and mortality of the Brugada-type
electrocardiogram in one city in Japan.  J Am Coll Cardiol 2001;38:771-774.)

De aproximadamente 12,000 pacientes não cardíacos procedentes de um Hospital
Universitário coletados em forma prospectiva em um período de 2 anos se
encontraram 52 casos com o típico padrão eletrocardiográfico Brugada Ex com
o sinal de Brugada (Monroe MH, Littmann L. Two-year case collection of the
Brugada syndrome electrocardiogram pattern at a large teaching hospital.
Clin Cardiol. 2000;23:849-851.)

Numa publicação procedente  da França tem mostrado uma prevalência do padrão
eletrocardiográfico Brugada de 1 cada 1000 entre indivíduos assintomáticos
(Hermida J, Lemoine J, Aoun FB, et al.: Prevalence of the Brugada syndrome
in an apparently healthy population. Am J Cardiol; 2000; 86:91-94.).

A prevalência, incidência e prognóstico do padrão Eletrocardiográfico
Brugada na população geral do Japão num estudo de 4 décadas  De 4788
indivíduos 32 padrões ECG Brugada foram detectados a prevalência e
incidência foi de 146.2 em 100,00 habitantes e 14.2 por 100.000 indivíduos
/ano respectivamente.

Esta incidência foi 9 vezes mais alta em homens do que em mulheres e a
intermitência do padrão de ECG Brugada foi encontrada em 26% dos casos de
aqueles que tiveram MCS  e a análise de sobrevida Cox mostrou que a
mortalidade inesperada foi significativamente mayor em sujeitos com o padrão
ECG Brugada  ( Matsuo K, Akahoshi M, Nakashima E, et al. The prevalence,
incidence and prognostic value of the Brugada-type electrocardiogram: a
population-based study of four decades.  J Am Coll Cardiol 2001;
38:765-770.)

Monroe e  Littmann (2000), em 12,000 ECG consecutivos de pacientes no
cardíacos de um Hospital de ensino durante 2 anos encontraram o padrão ECG
Brugada em 52 mostrando uma prevalência mais elevada que a previamente
mostrada ( Monroe MH, Littmann L. Two-year case collection of the Brugada
syndrome electrocardiogram pattern at a large teaching hospital. Clin
Cardiol. 2000; 23:849-851.).

A prevalência e prognóstico dos sujeitos com o padrão eletrocardiográfico
Brugada foram estudado em 2479 homens jovens candidatos da força aérea com
idades entre 18 e 30 anos e em 542 pessoas de média idade sadias com idades
entre 40 e 60 anos na população da Finlândia. 15 sujeitos ( 0.62%) do
primeiro grupo e três do segundo ( 0.55%) preenchiam os critérios ECG do
padrão tipo 1 ou tipo 2. O tipo 1 coved não foi visto em nenhum sujeito . A
natureza benigna da evolução dos pacientes com o sinal de Brugada sugere que
em assintomáticos sem história familiar de MCS   ou tipo 2 ou 3 de padrão de
ECG é uma variante normal e não preditiva de arritmias ventriculares (
Junttila MJ, Raatikainen MJ, Karjalainen J, Kauma H, Kesaniemi YA, Huikuri
HV. Prevalence and prognosis of subjects with Brugada-type ECG pattern in a
young and middle-aged Finnish population. Eur Heart J. 2004; 25:874-878.).

A prevalência do padrão ECG Brugada induzido por drogas oi de 5 em 1000
pacientes Este valor foi 5 vezes maior que o reportado na forma esontânea da
síndrome de Brugada  na populaçõa sadia (Hermida JS, Jandaud S, Lemoine JL,
Rodriguez-Lafrasse C, Delonca J, Bertrand C, Jarry G, Rochette J, Rey JL.
Prevalence of drug-induced electrocardiographic pattern of the Brugada
syndrome in a healthy population. Am J Cardiol. 2004; 94:230-233. )

Saludações

Andrés Ricardo Pérez Riera

>
> English - Spanish
>
> Dear Andres,
>
> Dr Wlodarska expressed a correct opinion, based on evidence based data.
> You well know that the data which You enphasize on the "so called" Brugada
> Syndrome are mostly derived from opinions and not epidemiological data. In
> the far east detailed necropsy study and preventive cardiological
> examination are not much available, so data on the underlying basis of
> sudden death are presumed and not proved.
> It must be clarified that an ECG is not a syndrome.
> The discussed ECG is not so rare, but the syndrome, firtly described in
> Italy, is rare as pointed out by more than an epidemiological study,
> http://digilander.libero.it/martini_syndrome/page26.html
> Recent surveys in Finland and Japan, are also more restrictive.
> A big mistake to avoid is to presume (without any evidence based data),
> that the unrare healthy people with this ECG will suffer of the syndrome,
> in which case the "so called"  Brugada syndrome should be a problem bigger
> than AIDS, as pointed out by Dr Littmann in his letter: "The Brugada
> Numbers" Circulation. 2003 May 1;107(18):e122;
> Your statement "Brugada syndrome is believed to be responsible of 4-12% of
> all SCD and around 20% of death with structural normal hearts".  has not
> been proven by any well evidence based serie.
> Moreover, almost all the patients died suddenly with this syndrome, and
> submitted to a detailed necropsy study,  had a structural heart disease, of
> the conduction system (as demonstrated decades ago by Kirschner), and of
> the right ventricular Outflow tract,  as re-established also in a recent
> abstract, unfortunately not yet published:  ?A multicenter histological
> study of autopsied and biopsied specimens in BS?. Morimoto S. Eur Heart J
> 2003;24:147.
> As a conclusion I would like to answer to   Jose Luiz Pantaleon Albornoz
> Padilla from Malaga.
> My point of view on the "so called" Brugada syndrome is that this syndrome
> (not the ECG), is an organic heart disease closely linked to ARVD/C
> My opinions can be read in the following article.
>
> http://www.italheartj.org/pdf_files/Martini.pdf
>
> Bortolo Martini  MD
>
> ---------------------
>
> Estimado Andres:
> La Dra. Wlodarska expreso una opinion correcta, basandose en informacion
> basada en evidencia. Usted bien sabe que la informacion que Ud. enfatiza en
> el "llamado" Sindrome de Brugada deriva principalmente de opiniones y no de
> datos epidemiologicos. En el lejano oriente, el estudio de la necropsia
> detallada y el examen cardiologico preventivo no estan demasiado
> disponibles, de modo que la informacion sobre las bases subyacentes de la
> muerte subita es supuesta y no comprobada.
> Debe quedar claro que un ECG no es un sindrome.
> El ECG que se discute no es tan raro, pero el sindrome, primeramente
> descrito en Italia, es raro como lo seniala mas de un estudio
> epidemiologico,
> http://digilander.libero.it/martini_syndrome/page26.html
> Encuestas recientes en Finlandia y Japon tambien son mas restrictas.
> Un gran error que hay que evitar es suponer (sin ninguna informacion basada
> en evidencia) que las personas comunmente saludables con este ECG padecen
> el sindrome, en cuyo caso el "llamado" Sindrome de Brugada deberia ser un
> problema mas grande que el SIDA, como lo senialo el Dr. Littmann en su
> carta: "Los Numeros de Brugada" Circulation.
> 2003 May 1;107(18):e122;
> Su afirmacion de que se cree que el Sindrome de Brugada es responsable de
> un 4-12% de todas las MS y de alrededor del 20% de las muertes con
> corazones estructuralmente normales, no se ha comprobado por ninguna serie
> basada en evidencia.
> Ademas, casi todos los pacientes que murieron subitamente con este
> sindrome, y que fueron sometidos a un estudio detallado de necropsia,
> tenian una cardiopatia estructural del sistema de conduccion (como lo
> demostro Kirschner hace decadas) y del tracto de salida del ventriculo
> derecho, como se reestablecio tambien en un resumen reciente,
> desafortunadamente no publicado todavia: "A multicenter histological study
> of autopsied and biopsied specimens in BS". Morimoto S. Eur Heart J
> 2003;24:147.
> Como conclusion, me gustaria responder a Jose Luiz Pantaleon Albornoz
> Padilla de Malaga.
> Mi punto de vista acerca del "llamado" Sindrome de Brugada es que este
> sindrome (no el ECG), es una cardiopatia organica estrechamente vinculada
> con la M/DAVD. Mis opiniones se pueden leer en el siguiente articulo.
>
> http://www.italheartj.org/pdf_files/Martini.pdf
>
> Bortolo Martini  MD
>
> > English - Spanish
> >
> > Dear Andres,
> >
> > I am fully aware of the data you quoted and I want to emphasize that ARVD
> > is most likely underdiagnozed entity. recognized mostly by tertiary
> > centers. Increasing awareness about ARVD, through variety of educational
> > programs including this symposium, will contribute to more frequent
> > diagnosis of this disorder. Looking back 10 years ago, diagnosis of LQTS
> > was quite infrequent, decade later physicans know it well and diagnose it
> > more frequently. The same pattern hopefully will be followed by ARVD.
> >
> > The paper by Dr. Wlodarska is of major importance reconfirming familial
> > form of the disorder in the majority of cases with various penetrance
> > among studied families. This observation further prompts physicians to
> > evaluate and monitor family members of ARVD probands.
> >
> > The data from autopsy of athletes are very intiguing, but could represent
> > biased sample. There is a theory that vigorous physical activity might
> > contibute to expression of otherwise silent ARVD genes. Overstrech of
> > right ventricle (both ventricles) during athletic activities might be the
> > factor turnning on clinical form of ARVD. More studies are needed to
> > determine this potential association.
> >
> > Best regards
> >
> > Wojciech Zareba
> >
> > ------------------------
> >
> > Estimado Andres,
> >
> > Soy totalmente consciente de la informacion que cita y deseo enfatizar
> > que la DAVD es muy probablemente, una entidad subdiagnosticada,
> > reconocida principalmente por centros terciarios. Una mayor conciencia
> > sobre la DAVD, a traves de una variedad de programas educativos
> > incluyendo este simposio, contribuira a una diagnostico mas frecuente de
> > este trastorno. Mirando hacia atras, hace 10 anios el diagnostico de LQTS
> > era bastante poco frecuente; pero una decada mas tarde los medicos la
> > conocen bien y la diagnostican con mayor frecuencia. Esperemos que se
> > siga el mismo patron con la DAVD.
> >
> > El trabajo de la Dra. Wlodarska es sumamente importante, y reconfirma la
> > forma familiar de este trastorno en la mayoria de los casos con
> > penetrancias diversas en las familias estudiadas. Esta observacion anima
> > aun mas a los medicos a evaluar y monitorear a los parientes de los casos
> > testigos con DAVD.
> >
> > Los datos de las autopsias de los atletas son muy intrigantes, pero
> > pueden representar una muestra parcializada. Hay una teoria que establece
> > que la actividad fisica vigorosa puede contribuir con la expresion de los
> > genes DAVD que de lo contrario permanecen silentes. El sobreestiramiento
> > del ventriculo derecho (ambos ventriculos) durante las actividades
> > atleticas puede ser el factor que activa la forma clinica de la DAVD. Se
> > necesitan mas para determinar esta asociacion potencial.
> >
> > Saludos cordiales,
> >
> > Wojciech Zareba
> >
> > > English - Portuguese
> > >
> > > Dear Dr .Zareba,
> > > Here Andrés Ricardo Pérez Riera form São Paulo Brazil.
> > > Prevalence of ARVC/D is estimated as 1/5000 (Czarnowska E, Wlodarska
> > > EK, Zaleska T.  Arrhythmogenic right ventricular cardiomyopathy
> > > (dysplasia): etiology, clinical presentation, diagnosis and treatment
> > > Kardiol Pol. 2003; 58:58-63.)
> > >
> > > The prevalence is estimated at 0.4% depending on geographic
> > > circumstances. (Hagenah G, Andreas S, Konstantinides S. Accidental left
> > > ventricular placement of a defibrillator probe due to a patent foramen
> > > ovale in arrhythmogenic right ventricular dysplasia. Acta Cardiol.
> > > 2004; 59:449-451.) like Brugada Syndrome. The entity is endemic in
> > > Veneto region (Italy), Nova Scotia and Naxus Greek island (recesive
> > > form). The incidence of SCD is approximately 2.5% a year. In the
> > > athletes group < 35 years, ARVC/D is the more important cause of death
> > > in Europe. Studies have shown that ARVC/D is a significant cause of SCD
> > > among young athletes despite, circumstances of death are various, but
> > > 75.6% occurred during everyday life events (at home, 63.1%; in the
> > > street, 6.6%; or at work, 6.1%); only 3.5% occurred during sports
> > > activity. (Tabib A, Loire R, Chalabreysse L, et al Circumstances of
> > > death and gross and microscopic observations in a series of 200 cases
> > > of sudden death associated with arrhythmogenic right ventricular
> > > cardiomyopathy and/or dysplasia. Circulation. 2003;
> > > 108:3000-3005).
> > >
> > >  ARVC/D may account for as many as 5% of unexpected SCD under the age
> > > of 65 and 3-4% of SCD during sports.
> > >
> > > ARVC/D is an important cause of SCD in the young.
> > >
> > > Best regard
> > >
> > > Andres
> > >
> > > -----------------------
> > >
> > > Portuguese
> > >
> > > Prezado Dr Zareba:
> > > Aqui Andrés Ricardo Pérez Riera de São Paulo Brasil. A prevalencia da
> > > DAVD se ha estimando en 1/5000, o 0.4% dependendo de circuntâncias
> > > geográficas. Como a sindrome de Brugada  tiene areas endémicas, como na
> > > região de Veneto na Italia nova Escocia e na ilha grega de Naxos (na
> > > forma recessiva). Entre jovens atletas menores de 35 anos é a principal
> > > causa de morte na Europa. Estudos tem mostrado que a DAVD é uma causa
> > > significativa de MCS entre atletas porem as circunstacias da morte são
> > > varias 75,6% ocorrem durante o dia no lar; 63% na rua;  6.6% no
> > > trabalho 6,1% e apenas em  3,5% durante a atividade esportiva. A la
> > > DAVD se le pode atribuir tanto quanto 5% das mortes subitas inesperada
> > > abaixo de 65 anos e 3-4% das MCS durante esportes. A DAVD é uma
> > > importante causa de morte no jovem.
> > >
> > > Saludacoes
> > >
> > > Andres.
> > >
> > > > English - Spanish
> > > > Dear Guy,
> > > >
> > > > We definitely value your opinion and it could well be that the
> > > > disease is largely underestimated. At least when we compare with
> > > > number of cases seen clinically of LQTS, HCM, even Brugada syndrome,
> > > > ARVD is far behind, very rare.
> > > >
> > > > But, the virtual symposium is exactly good forum to express such
> > > > opinions and
> > > > we appreciate you writing a paragraph on it and we will send your
> > > > comment to all participants.
> > > >
> > > > Best regards
> > > >
> > > > Wojciech
> > > >
> > > > ----------------------
> > > >
> > > > Estimado Guy:
> > > >
> > > > Definitivamente valoramos tu opinion y bien podria ser que la
> > > > enfermedad este enormemente menospreciada. Por lo menos cuando la
> > > > comparamos con el numero de casos vistos clinicamente de LQTS, CMH,
> > > > incluso del Sindrome de Brugada, la DAVD esta muy por detras con
> > > > respecto a las otras, por eso es rara.
> > > >
> > > > Pero el Simposio Virtual es exactamente el foro para expresar tales
> > > > opiniones, y apreciamos que escribas un parrafo al respecto. Nosotros
> > > > enviaremos tus comentarios a todos los participantes.
> > > >
> > > > Saludos cordiales,
> > > >
> > > > Wojciech
> > > >
> > > >
> > > > t _______________________________________
> > > >
> > > > > English - Spanish
> > > > >
> > > > > Dear Wojciech
> > > > >
> > > > > I do not agree with the statement that ARVD is a rare disease !
> > > > >
> > > > > The histologic substrate of RVD is found in 3.7 % of the general
> > > > > population
> > > > >
> > > > > only few patients are referred to tertiary centers because of
> > > > > arrhythmias.
> > > > >
> > > > > Around 3-5 cases each month are seen in Paris in the Forensic
> > > > > Medicine Institution
> > > > >
> > > > > 10 cases are studied each day !
> > > > >
> > > > > In addition many patients have concealed RV dysfunction. This is
> > > > > visible only in case of independent LV failure
> > > > > Therefore ARVD and Fat Dissociation Syndrome (see my
> > > > > histopathologic plates) are important pronostic factors as recently
> > > > > reported.
> > > > >
> > > > > Best regards
> > > > >
> > > > > Guy
> > > > >
> > > > > ----------------
> > > > >
> > > > > Estimado Wojciech
> > > > >
> > > > > No coincido con la idea de que la DAVD es una enfermedad rara!
> > > > > El sustrato histologico de DVD se encuentra en el 3,7 % de la
> > > > > poblacion general, solo unos pocos pacientes son derivados a
> > > > > centros terciarios debido a arritmias.
> > > > >
> > > > > En Paris se ven alrededor de 3-5 casos por mes; en la Forensic
> > > > > Medicine Institution se estudian 10 casos cada dia!
> > > > >
> > > > > Ademas, muchos pacientes tienen disfuncion oculta del VD. Esto solo
> > > > > es evidente en el caso de insuficiencia independiente del VI.
> > > > > Por lo tanto, la DAVD y el Sindrome de Disociacion de Adiposidad
> > > > > (ver mis placas histopatologicas) son factores de pronostico
> > > > > importantes como se informo recientemente.
> > > > >
> > > > > Saludos cordiales,
> > > > >
> > > > > Guy
>
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Dr. Sergio Dubner
Director

Dr. Edgardo Schapachnik
Director