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1.
Article in English | WPRIM | ID: wpr-890512

ABSTRACT

Background@#Obesity is a chronic disease associated with metabolic diseases such as diabetes and cardiovascular disease. Since the U.S. Food and Drug Administration approved liraglutide as an anti-obesity drug for nondiabetic patients in 2014, it has been widely used for weight control in overweight and obese people. This study aimed to systematically analyze the effects of liraglutide on body weight and other cardiometabolic parameters. @*Methods@#We investigated articles from PubMed, EMBASE, and the Cochrane Library to search randomized clinical trials that examined body weight changes with liraglutide treatment. @*Results@#We included 31 studies with 8,060 participants for this meta-analysis. The mean difference (MD) between the liraglutide group and the placebo group was −4.19 kg (95% confidence interval [CI], −4.84 to −3.55), with a −4.16% change from the baseline (95% CI, −4.90 to −3.43). Liraglutide treatment correlated with a significantly reduced body mass index (MD: −1.55; 95% CI, −1.76 to −1.34) and waist circumference (MD: −3.11 cm; 95% CI, −3.59 to −2.62) and significantly decreased blood pressure (systolic blood pressure, MD: −2.85 mm Hg; 95% CI, −3.36 to −2.35; diastolic blood pressure, MD: −0.66 mm Hg; 95% CI, −1.02 to −0.30), glycated hemoglobin (MD: −0.40%; 95% CI, −0.49 to −0.31), and low-density lipoprotein cholesterol (MD: –2.91 mg/dL; 95% CI, −5.28 to −0.53; MD: −0.87% change from baseline; 95% CI, −1.17 to −0.56). @*Conclusion@#Liraglutide is effective for weight control and can be a promising drug for cardiovascular protection in overweight and obese people.

2.
Article in English | WPRIM | ID: wpr-889346

ABSTRACT

Ketamine is used widely in emergency departments for a variety of purposes, including procedural sedation for facial laceration in pediatric patients. The major benefits are its rapid onset of effects, relatively short half-life, and lack of respiratory depression. The known side effects of ketamine are hallucinations, dizziness, nausea, and vomiting. Seizure is not a known side effect of ketamine in patients without a seizure history. Here, we present the case of a patient in whom ketamine likely induced a generalized tonic-clonic seizure when used as a single agent in procedural sedation for facial laceration repair. The aim of this article is to report a rare and unexpected side effect of ketamine used at the regular dose for procedural sedation. This novel case should be of interest to not only emergency physicians but also plastic surgeons.

3.
Article in English | WPRIM | ID: wpr-899609

ABSTRACT

TCA is widely used in cosmetic treatments such as chemical peels, tattoo removal, and also in gynecological procedures for managing cervical intraepithelial neoplasia. However, storage of high concentration of TCA in a gynecology office is a potential hazard, as it may accidentally cause severe chemical burns. We report a case of deep dermal TCA chemical burn on genital area, which occured accidentally and resulted from misuse of high concentration (90%) of TCA coated vaginal gauze packing dressing during gynecological procedures.

4.
Article in English | WPRIM | ID: wpr-898216

ABSTRACT

Background@#Obesity is a chronic disease associated with metabolic diseases such as diabetes and cardiovascular disease. Since the U.S. Food and Drug Administration approved liraglutide as an anti-obesity drug for nondiabetic patients in 2014, it has been widely used for weight control in overweight and obese people. This study aimed to systematically analyze the effects of liraglutide on body weight and other cardiometabolic parameters. @*Methods@#We investigated articles from PubMed, EMBASE, and the Cochrane Library to search randomized clinical trials that examined body weight changes with liraglutide treatment. @*Results@#We included 31 studies with 8,060 participants for this meta-analysis. The mean difference (MD) between the liraglutide group and the placebo group was −4.19 kg (95% confidence interval [CI], −4.84 to −3.55), with a −4.16% change from the baseline (95% CI, −4.90 to −3.43). Liraglutide treatment correlated with a significantly reduced body mass index (MD: −1.55; 95% CI, −1.76 to −1.34) and waist circumference (MD: −3.11 cm; 95% CI, −3.59 to −2.62) and significantly decreased blood pressure (systolic blood pressure, MD: −2.85 mm Hg; 95% CI, −3.36 to −2.35; diastolic blood pressure, MD: −0.66 mm Hg; 95% CI, −1.02 to −0.30), glycated hemoglobin (MD: −0.40%; 95% CI, −0.49 to −0.31), and low-density lipoprotein cholesterol (MD: –2.91 mg/dL; 95% CI, −5.28 to −0.53; MD: −0.87% change from baseline; 95% CI, −1.17 to −0.56). @*Conclusion@#Liraglutide is effective for weight control and can be a promising drug for cardiovascular protection in overweight and obese people.

5.
Article in English | WPRIM | ID: wpr-897050

ABSTRACT

Ketamine is used widely in emergency departments for a variety of purposes, including procedural sedation for facial laceration in pediatric patients. The major benefits are its rapid onset of effects, relatively short half-life, and lack of respiratory depression. The known side effects of ketamine are hallucinations, dizziness, nausea, and vomiting. Seizure is not a known side effect of ketamine in patients without a seizure history. Here, we present the case of a patient in whom ketamine likely induced a generalized tonic-clonic seizure when used as a single agent in procedural sedation for facial laceration repair. The aim of this article is to report a rare and unexpected side effect of ketamine used at the regular dose for procedural sedation. This novel case should be of interest to not only emergency physicians but also plastic surgeons.

6.
Article in English | WPRIM | ID: wpr-891905

ABSTRACT

TCA is widely used in cosmetic treatments such as chemical peels, tattoo removal, and also in gynecological procedures for managing cervical intraepithelial neoplasia. However, storage of high concentration of TCA in a gynecology office is a potential hazard, as it may accidentally cause severe chemical burns. We report a case of deep dermal TCA chemical burn on genital area, which occured accidentally and resulted from misuse of high concentration (90%) of TCA coated vaginal gauze packing dressing during gynecological procedures.

7.
Journal of Korean Diabetes ; : 225-237, 2021.
Article in Korean | WPRIM | ID: wpr-918905

ABSTRACT

The accuracy and convenience of continuous glucose monitoring (CGM), which efficiently evaluates glycemic variability and hypoglycemia, are improving. There are two types of CGM: professional CGM and personal CGM. Personal CGM is subdivided into real-time CGM (rt-CGM) and intermittently scanned CGM (isCGM). CGM is being emphasized in both domestic and foreign diabetes management guidelines. Regardless of age or type of diabetes, CGM is useful for diabetic patients undergoing multiple insulin injection therapy or using an insulin pump. rt-CGM is recommended for all adults with type 1 diabetes (T1D), and can also be used in type 2 diabetes (T2D) treatments using multiple insulin injections. In some cases, short-term or intermittent use of CGM may be helpful for patients with T2D who use insulin therapy other than multiple insulin injections and/or oral hypoglycemic agents. CGM can help to achieve A1C targets in diabetes patients during pregnancy. CGM is a safe and cost-effective alternative to self-monitoring blood glucose in T1D and some T2D patients. CGM used in diabetes management works optimally with proper education, training, and follow up. To achieve the activation of CGM and its associated benefits, it is necessary to secure sufficient repetitive training and time for data analysis, management, and education. Various supports such as compensation, insurance coverage expansion, and reimbursement are required to increase the effectiveness of CGM while considering the scale of benefit recipients, policy priorities, and financial requirements.

8.
Article in English | WPRIM | ID: wpr-915323

ABSTRACT

Purpose@#Frostbite is a hazard to people exposed to cold environments. With the progression of modern industrial development and change of leisure behavior encountering cold environments, frequent accidental exposure to frostbite injury during work and human behavior is increasing, and the predisposing factors of frostbite were greatly changed than before. The purpose of this study was to make epidemiological analysis, and to review the treatment outcomes of frostbite. @*Methods@#From March 2010 to February 2021, this study has included 27 patients with second- to third-degree frostbite injuries in Advanced Burn Reconstruction Center, Bundang Jesaeng Hosptial. A retrospective study was made about the distribution of age, gender, predisposing factors, prevalent area, type of managements, and the length of treatment period. @*Results@#In our institution, acute management of frostbite patients has included rewarming, anticoagulation therapy (acetylsalicylic acid), and agents to improve vascular perfusion (lipo-prostaglandin E1 [Eglandin Ⓡ ]). The 25 frostbite patients with second-degree frostbite (92.6%) were successfully managed by the conservative treatment alone with a mean of 20.3 days healing time. Two patients with third-degree frostbite (7.4%) also showed good outcomes after surgical reconstruction with a mean of 59 days healing time. In our clinical experiences of third-degree frostbite, definitive surgical reconstruction should be recommended to wait for more than 4∼6 weeks for identification of clear demarcation of necrotic tissue caused by frostbite. In this study, 43 frostbite injuries site in 27 frostbite patients occurred. Among them, 15 patients (55.6%) had multiple-site frostbite injury. The most common predisposing cause of frostbite was refrigerant gas accidents (44.4%), followed by outdoor activity in cold environments (40.8%), misapplying ice pack for treatment purposes (7.4%), barefoot walking on the cold ground (3.7%), and loss of consciousness in cold grounds (3.7%). The most prevalent sites of frostbite injuries revealed as the hand (58.1%), followed by the foot (32.6%), face (7.0%), and abdomen (2.3%). And in the winter season from the November to March, the incidence rate of frostbite injuries was high at 74.1%. @*Conclusion@#This study included 27 frostbite patients with 43 frostbite sites since last decade in a single institution at the com -munity hospital. The frostbite patients with second-degree frostbite (92.6%) were successfully healed by the conservative treatment alone with a mean of 20.3 days healing time. The most common predisposing cause of frostbite was refrigerant gas accidents (44.4%), followed by outdoor activity in cold environments, etc. The most prevalent site of frostbite injuries was the hand (58.1%). And the most prevalent seasonal incidence of frostbite was from November to March (74.1%).

10.
Article | WPRIM | ID: wpr-835934

ABSTRACT

Purpose@#Due to rapid changes in the industrial structure in last decade, the wider various types of chemical agents were introduced. Burn surgeons should be well-informed with rapid changes of chemical burns. We present the recent incidence trends of causing agents of chemical burns. @*Methods@#From 2010 to 2019, 92 chemical burn victims were included in this study. A retrospective study was made about the type, distribution and incidence of the causing agents of chemical burns. Initial treatments of most chemical burn wounds are copious saline irrigation by tap water, except hydrofluoric acid burn cases managed by 10% calcium gluconate injection. In alkali chemical burns on extremity, if thin eschars appear in postburn 2∼3 days, acute early surgical escharectomy and split thickness skin graft were done. @*Results@#More than 9 types of major chemicals causing chemical burns were surveyed, and the most common causing agent of chemical burns was Hydrofluoric acid (23.9%) followed by Acetic acid (19.6%) and Sodium hydroxide (8.7%). @*Conclusion@#From 2010 to 2019, changes in the causing agent of chemical burns are that the types of major causing agents of chemical burns have increased and the distribution and incidence of causing agents have changed compared to previous reports. According to this study, more than 9 types of major chemicals causing chemical burns were surveyed, and the most common causing agent of chemical burns was Hydrofluoric acid (23.9%) followed by Acetic acid, Sodium hydroxide.

11.
Article | WPRIM | ID: wpr-835931

ABSTRACT

This paper presents our clinical experiences for reconstruction of the linear depressed postburn scar band by rhombus subcutaneous pedicle skin flap (RSPF). We report new RSPF, it’s versatility, and effectiveness for correction of the mild to moderate linear depressed postburn scar band. To correct the postburn scar band, we have newly designed the Rhombus Subcutaneous Pedicle Skin Flap (RSPF), which is made as rhombus-shaped skin flap on the inside of scar band. After excision of burn scar band, the each vertex of RSPF flap is advanced into the skin defects at apex of extended skin incision, which is starting from the upper and lower portion of the removed burn scar band at a near right angle. This flap can add more extra skin to adjacent superior and inferior area of excised scar band. We have experienced 2 cases of RSPF for reconstruction of linear depressed postburn scar band deformities in lower extremity. After 3 weeks to 3 months postoperative follow ups, relatively satisfactory results were obtained in all cases. We had successfully reconstructed the linear depressed postburn scar postburn band of lower extremity using the rhombus subcutaneous pedicle skin flap. For the correction of mild to moderate sized linear depressed postburn scar band deformities in extremity, the RSPF is simple, and very effective without donor morbidity.

12.
Article in English | WPRIM | ID: wpr-835925

ABSTRACT

High-intensity focused ultrasound (HIFU) has been regarded as a non-invasive uterine-preserving treatment for women with uterine myoma. Numerous studies have reported that it is a relatively safe and effective treatment for uterine myoma.However, severe complications, such as deep thermal burn injuries, bowel perforation, and bladder injury, were reported on rare occasions. We report a case of a 4th degree burn on the lower abdomen after HIFU treatment for uterine myoma.Physicians must consider the possibility of deep thermal burn injuries when managing uterine myoma with HIFU.

13.
Article | WPRIM | ID: wpr-832406

ABSTRACT

Growth hormone (GH) deficiency is caused by congenital or acquired causes and occurs in childhood or adulthood. GH replacement therapy brings benefits to body composition, exercise capacity, skeletal health, cardiovascular outcomes, and quality of life. Before initiating GH replacement, GH deficiency should be confirmed through proper stimulation tests, and in cases with proven genetic causes or structural lesions, repeated GH stimulation testing is not necessary. The dosing regimen of GH replacement therapy should be individualized, with the goal of minimizing side effects and maximizing clinical improvements. The Korean Endocrine Society and the Korean Society of Pediatric Endocrinology have developed a position statement on the diagnosis and treatment of GH deficiency. This position statement is based on a systematic review of evidence and expert opinions.

14.
Article in English | WPRIM | ID: wpr-830588

ABSTRACT

Striae gravidarum are a common problem in postpartum women, who may experience serious emotional distress due to multiple streaks of scars on the abdomen. There is still no consensus on the treatment method for this problem. For a postpartum woman in her late 30s, who requested striae removal from the lower mid-abdomen, we developed and performed the keyhole-shaped vertical mini-abdominoplasty. This 37-year-old woman, who had given birth to two children, presented with multiple striae on the lower mid-abdomen and periumbilical area, as well as mild bulging in this area. The keyhole-shaped vertical mini-abdominoplasty, including multiple striae on the lower mid-abdomen and periumbilical skin, was designed. An area of striated lower abdominal and periumbilical skin, measuring approximately 10×15 cm2 and weighing about 450 g, was excised. Midline reinforcement of the loosened anterior rectus sheath with 3-0 Prolene sutures was done. Both lateral abdominal skin flaps were medially advanced to close the skin defects. Postoperatively, the patient had a favorable lower abdominal appearance with markedly fewer striae on the lower mid-abdomen and periumbilical area. The keyhole vertical mini-abdominoplasty can effectively correct moderate striae on the lower mid-abdomen and periumbilical area in postpartum women in their late 30s to middle age.

15.
Journal of Korean Diabetes ; : 233-238, 2019.
Article in Korean | WPRIM | ID: wpr-786603

ABSTRACT

Tight control of dyslipidemia and hypertension in elderly diabetic patients aged 65 years or older are considered to be very important for the secondary prevention of cardiovascular disease and control of severe diseases associated with macrovascular complications. In addition, in elderly diabetes with risk factors for cardiovascular disease, it is important to control all of the accompanying risk factors together to accomplish the primary prevention of cardiovascular disease. In elderly diabetic patients, thorough control of blood glucose level by itself prevents macrovascular complications. However, it is recommended to perform tight blood glucose control along with other risk factors in consideration of the function and life of the patient. In particular, insulin resistance progresses before the onset of diabetes mellitus and other risk factors for cardiovascular disease. It is important to suppress and prevent the progression of macrovascular complications.


Subject(s)
Aged , Blood Glucose , Cardiovascular Diseases , Diabetes Mellitus , Dyslipidemias , Humans , Hypertension , Insulin Resistance , Primary Prevention , Risk Factors , Secondary Prevention
16.
Article in English | WPRIM | ID: wpr-763670

ABSTRACT

The Committee of Clinical Practice Guidelines of the Korean Diabetes Association revised and updated the 6th Clinical Practice Guidelines in 2019. Targets of glycemic, blood pressure, and lipid control in type 2 diabetes mellitus (T2DM) were updated. The obese and overweight population is increasing steadily in Korea, and half of the Koreans with diabetes are obese. Evidence-based recommendations for weight-loss therapy for obesity management as treatment for hyperglycemia in T2DM were provided. In addition, evidence from large clinical studies assessing cardiovascular outcomes following the use of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists in patients with T2DM were incorporated into the recommendations.


Subject(s)
Blood Pressure , Diabetes Mellitus, Type 2 , Diagnosis , Glucagon-Like Peptide 1 , Humans , Hyperglycemia , Korea , Obesity , Overweight
17.
Article in Korean | WPRIM | ID: wpr-715479

ABSTRACT

PURPOSE: It is well known the advantages of scalp donor split thickness skin graft(STSG) in deep burn wound because of its scarless donor healing, and good color match in face. Inspite of the advantages of scalp as a skin donor site during split thickness skin graft some authors report the frequent postoperative folliculitis, and partial alopecia on scalp donor site. We had experienced 21 burn patients, who had full thickness skin defects caused by burn injuries, were successfully managed with scalp donor split thickness skin graft with our optimal donor management protocols. METHODS: We had 21 deep burn patients, who were managed with thin STSG from scalp donor for coverage of full thickness skin defects. The operative techniques of the harvesting scalp STSG, and scalp donor dressing care are such as followings. After the infiltration of the donor scalp area with 1:1,000,000 epinephrine diluted with saline, then usually 0.012~0.015 inch thickness skin were harvested with air driven Zimmer® dermatome. On postoperative 6days, the one layer of adhered Vaseline gauze at donor scalp site was manually removed, and the entire scalp was cleansed with water. After then the daily hair washing was continued to remove the desiccated scaly crust with thick exudate at the growing hair and follicle. RESULTS: The scalp split thickness skin graft at the recipient sites in 21 burn patients were survived completely. Ranges of patient's age were 8 months to 56. The size ranges of scalp STSG were 2×2 cm~12×15 cm. The grafted scalp donor STSG were survived in all cases. The mean epithelialization period of scalp donor was 7.2 days. The one case of transient folliculitis (5%) from the postoperative 8days was occurred, and it was disappeared slowly with vigorous daily hair washing, antiseptics and systemic antibiotics. In all cases, there was no micro-alopecia or alopecia, and scars in scalp donor after follow ups. The donor site pain was markedly disappeared within 1~2 postoperative day. The hemorrhage from the scalp donor site during operation was not noticeable. The newly growing hair at the scalp donor was noted from the 3 postoperative days by palpation or unaided eye through the Vaseline gauze dressing. The average lengths of newly growing hair shaft are 2~3 mm in postoperative 8 days, 5~6 mm in postoperative 14 days. CONCLUSION: We had successful reconstruction of postburn skin defects using scalp donor split thickness skin graft without donor scars, persistent folliculitis or alopecia on scalp donor. From the postoperative 6~7 days after harvesting the scalp donor STSG, early vigorous daily washing with water and open dressing of scalp donor site should be recommended in order to prevent folliculitis. After long-term follow ups, the scalp split skin grafted recipient sites showed reliable, and relatively good color match with surrounding skin in face and dorsum of hand.


Subject(s)
Alopecia , Anti-Bacterial Agents , Anti-Infective Agents, Local , Bandages , Burns , Cicatrix , Epinephrine , Exudates and Transudates , Folliculitis , Follow-Up Studies , Hair , Hand , Hemorrhage , Humans , Palpation , Petrolatum , Scalp , Skin , Tissue Donors , Transplants , Water , Wounds and Injuries
18.
Article in Korean | WPRIM | ID: wpr-741035

ABSTRACT

OBJECTIVES: This study examined the consumption of Han-sik and its association with the years of residence in Korea and the socioeconomic status among Filipino immigrant women of the Filipino Women's Diet and Health Study (FiLWHEL). METHODS: A total of 474 Filipino women married to Korean men were included in the analysis. Their dietary intake was assessed using a single-day 24-hour recall. The participants provided information on the demographics, socioeconomic, and health-related factors through face-to-face interviews. The generalized linear model and logistic regression model were used to examine the association between the socioeconomic status and consumption of Han-sik. RESULTS: The mean age of the participants was 34.3 years old, and the average duration of residence in Korea was 8.2 years. Among 474 Filipino women, a total of 467 consumed Han-sik, with an average of 6.8 food items per day. The Han-sik foods that the participants consumed most frequently were rice, cabbage kimchi, mixed-grain rice, and fried eggs. The average ratio of Han-sik was 58.57%. The ratio of Han-sik showed no significant associations with the years of residence, years of living together with their husband, education levels, total annual family income, or linguistic competence of Korean. However, the ratio of Han-sik use was associated with cohabitation with parents-in-law; the odds ratio (95% confidence interval) was 2.41 (1.18–4.92, p-trend = 0.002) comparing the fourth quartile with the first quartile of the Han-sik ratio. CONCLUSIONS: Filipino immigrant women in the FiLWHEL study consumed a larger number of Han-sik than Philippine foods. In addition, cohabitation with their parents-in-law was associated with the consumption of Han-sik. Further epidemiologic studies will be needed to determine how the diet affects the health and wellbeing of immigrant women in Korea.


Subject(s)
Brassica , Demography , Diet , Education , Eggs , Emigrants and Immigrants , Epidemiologic Studies , Female , Humans , Korea , Linear Models , Linguistics , Logistic Models , Male , Mental Competency , Odds Ratio , Ovum , Social Class , Spouses
19.
Article in Korean | WPRIM | ID: wpr-740945

ABSTRACT

OBJECTIVES: This study examined the consumption of Han-sik and its association with the years of residence in Korea and the socioeconomic status among Filipino immigrant women of the Filipino Women's Diet and Health Study (FiLWHEL). METHODS: A total of 474 Filipino women married to Korean men were included in the analysis. Their dietary intake was assessed using a single-day 24-hour recall. The participants provided information on the demographics, socioeconomic, and health-related factors through face-to-face interviews. The generalized linear model and logistic regression model were used to examine the association between the socioeconomic status and consumption of Han-sik. RESULTS: The mean age of the participants was 34.3 years old, and the average duration of residence in Korea was 8.2 years. Among 474 Filipino women, a total of 467 consumed Han-sik, with an average of 6.8 food items per day. The Han-sik foods that the participants consumed most frequently were rice, cabbage kimchi, mixed-grain rice, and fried eggs. The average ratio of Han-sik was 58.57%. The ratio of Han-sik showed no significant associations with the years of residence, years of living together with their husband, education levels, total annual family income, or linguistic competence of Korean. However, the ratio of Han-sik use was associated with cohabitation with parents-in-law; the odds ratio (95% confidence interval) was 2.41 (1.18–4.92, p-trend = 0.002) comparing the fourth quartile with the first quartile of the Han-sik ratio. CONCLUSIONS: Filipino immigrant women in the FiLWHEL study consumed a larger number of Han-sik than Philippine foods. In addition, cohabitation with their parents-in-law was associated with the consumption of Han-sik. Further epidemiologic studies will be needed to determine how the diet affects the health and wellbeing of immigrant women in Korea.


Subject(s)
Brassica , Demography , Diet , Education , Eggs , Emigrants and Immigrants , Epidemiologic Studies , Female , Humans , Korea , Linear Models , Linguistics , Logistic Models , Male , Mental Competency , Odds Ratio , Ovum , Social Class , Spouses
20.
Hanyang Medical Reviews ; : 30-33, 2017.
Article in English | WPRIM | ID: wpr-91137

ABSTRACT

Gestational diabetes mellitus (GDM) is a frequent medical problem during pregnancy. It is associated with an increased risk of complications for GDM mother and the offspring. There is increasing evidence that GDM may increase the risk of future type 2 diabetes and cardiovascular disease in mothers, and may also increase the risk of obesity and diabetes in children. Therefore GDM affects health for a lifetime. The International Association of Diabetes and Pregnancy Study Groups (IADPSG) proposed a new screening approach for pre-diagnosed diabetes at the first prenatal visit and diagnostic criteria for GDM in accordance with perinatal outcomes. Nonetheless, controversies still exist about these issues. There is a positive linear association between increasing maternal glucose at oral glucose tolerance testing and risk of important perinatal outcomes. In managing the GDM patients, an individualized medical approach is essential. If maternal glucose levels have increased, insulin can be used to achieve glycemic targets. Postpartum screening for diagnosing of diabetes is essential for women with previous GDM.


Subject(s)
Cardiovascular Diseases , Child , Diabetes, Gestational , Diagnosis , Female , Glucose , Glucose Tolerance Test , Humans , Insulin , Mass Screening , Mothers , Obesity , Postpartum Period , Pregnancy
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