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Parry-Jones AR, Järhult SJ, Kreitzer N, Morotti A, Toni D, Seiffge D, Mendelow AD, Patel H, Brouwers HB, Klijn CJ, Steiner T, Gibler WB, Goldstein JN. Acute care bundles should be used for patients with intracerebral haemorrhage: An expert consensus statement. Eur Stroke J 2024; 9:295-302. [PMID: 38149323 DOI: 10.1177/23969873231220235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
PURPOSE Intracerebral haemorrhage (ICH) is the most devastating form of stroke and a major cause of disability. Clinical trials of individual therapies have failed to definitively establish a specific beneficial treatment. However, clinical trials of introducing care bundles, with multiple therapies provided in parallel, appear to clearly reduce morbidity and mortality. Currently, not enough patients receive these interventions in the acute phase. METHODS We convened an expert group to discuss best practices in ICH and to develop recommendations for bundled care that can be delivered in all settings that treat acute ICH, with a focus on European healthcare systems. FINDINGS In this consensus paper, we argue for widespread implementation of formalised care bundles in ICH, including specific metrics for time to treatment and criteria for the consideration of neurosurgical therapy. DISCUSSION There is an extraordinary opportunity to improve clinical care and clinical outcomes in this devastating disease. Substantial evidence already exists for a range of therapies that can and should be implemented now.
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Affiliation(s)
- Adrian R Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Susann J Järhult
- Department of Medical Sciences, Uppsala University, Emergency Department, Uppsala University Hospital, Uppsala, Sweden
| | - Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Policlinico Umberto I, University La Sapienza Rome, Italy
| | - David Seiffge
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | | | - Hiren Patel
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Hens Bart Brouwers
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Catharina Jm Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst, Frankfurt and Heidelberg University Hospital, Heidelberg, Germany
| | - Walter Brian Gibler
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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Xu L, Chen Y, Chen S, Wang G, Fu Y, Cai J, Yang X, Wu S, Miao C, Hong J. Relationship between resting heart rate and long-term outcomes in stabilized patients with myocardial infarction: A prospective community-based cohort study. Int J Cardiol 2024; 400:131811. [PMID: 38278489 DOI: 10.1016/j.ijcard.2024.131811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 01/11/2024] [Accepted: 01/22/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Resting heart rate (RHR) during hospitalization has been shown to be associated with adverse outcomes in patients with myocardial infarction (MI). This study aimed to evaluate the long-term prognostic effect of RHR during the stable phase after MI in post-MI patients. METHODS Patients who had prior or new-onset MI and RHR measurements during the stable period after MI between 2006 and 2018 in the community-based Kailuan Study were enrolled. RHR was divided into four groups based on quartiles. Cox regression analysis was used to analyze the association of RHR with primary composite outcome of all-cause death, hospitalization for heart failure (HF), stroke, and recurrent MI and its components. RESULTS A total of 4447 post-MI patients were included. During a median follow-up of 7.5 years, 1813 patients (40.8%) developed primary outcomes. Compared to RHR ≤67 bpm, patients with 72 < RHR ≤80 bpm and RHR >80 bpm had increased risks of primary outcome, with adjusted hazard ratios (95% confidence intervals) of 1.23 (1.08-1.40) and 1.35 (1.18-1.55), respectively. The risk of primary outcome increased by 12% (1.07-1.17) for each 10-bpm increase in RHR. Similar results were observed in all-cause death and hospitalization for HF. Restricted cubic splines revealed a linear relationship between RHR and primary outcome, all-cause death, and hospitalization for HF (P for nonlinearity >0.05). CONCLUSIONS RHR during the stable phase after MI was an independent predictor for primary outcome and all-cause death in post-MI patients, and RHR >72 bpm was associated with increased risk for primary outcome and all-cause death.
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Affiliation(s)
- Lina Xu
- Department of Critical Care Medicine, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Yonggang Chen
- Department of Cardiology, Tangshan Central Hospital, Tangshan, China
| | - Shuohua Chen
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
| | - Guodong Wang
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
| | - Yu Fu
- Department of Emergency and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingyi Cai
- Department of Emergency and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinying Yang
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shouling Wu
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China.
| | - Congliang Miao
- Department of Emergency and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Jiang Hong
- Department of Critical Care Medicine, Shanghai General Hospital of Nanjing Medical University, Shanghai, China.
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Lee TC, Leung WC, Ho C, Chiu MW, Leung IY, Wong YK, Roxanna LK, Sum CH, Lui DT, Cheung RT, Leung GK, Chan KH, Teo KC, Lau KK. Association of LDL-cholesterol <1.8 mmol/L and statin use with the recurrence of intracerebral hemorrhage. Int J Stroke 2024:17474930241239523. [PMID: 38429252 DOI: 10.1177/17474930241239523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
BACKGROUND Recent intensive low-density lipoprotein cholesterol (LDL-C) lowering trials, including FOURIER, ODYSSEY OUTCOMES, and Treat Stroke to Target (TST) trials, have mostly refuted the concern surrounding statin use, LDL-C lowering, and intracerebral hemorrhage (ICH) risk. However, the results from these trials may not be fully applied to ICH survivors, as the populations studied were mainly patients without prior ICH, in whom the inherent ICH risk is more than 10 times lower than that of ICH survivors. Although available literature on statin use after ICH has demonstrated no excess risk of recurrent ICH, other potential factors that may modify ICH risk, especially hypertension control and ICH etiology, have not generally been considered. Notably, data on LDL-C levels following ICH are lacking. AIMS We aim to investigate the association between LDL-C levels and statin use with ICH risk among ICH survivors, and to determine whether the risk differed with patients' characteristics, especially ICH etiology. METHODS Follow-up data of consecutive spontaneous ICH survivors enrolled in the University of Hong Kong prospective stroke registry from 2011 to 2019 were retrospectively analyzed. ICH etiology was classified as cerebral amyloid angiopathy (CAA) using the modified Boston criteria or hypertensive arteriopathy, while the mean follow-up LDL-C value was categorized as <1.8 or ⩾1.8 mmol/L. The primary endpoint was recurrent ICH. The association of LDL-C level and statin use with recurrent ICH was determined using multivariable Cox regression. Pre-specified subgroup analyses were performed, including based on ICH etiology and statin prescription. Follow-up blood pressure was included in all the regression models. RESULTS In 502 ICH survivors (mean age = 64.2 ± 13.5 years, mean follow-up LDL-C = 2.2 ± 0.6 mmol/L, 28% with LDL-C <1.8 mmol/L), 44 had ICH recurrence during a mean follow-up of 5.9 ± 2.8 years. Statin use after ICH was not associated with recurrent ICH (adjusted hazard ratio (AHR) = 1.07, 95% confidence interval (CI) = 0.57-2.00). The risk of ICH recurrence was increased for follow-up LDL-C <1.8 mmol/L (AHR = 1.99, 95% CI = 1.06-3.73). This association was predominantly observed in ICH attributable to CAA (AHR = 2.52, 95% CI = 1.06-5.99) and non-statin users (AHR = 2.91, 95% CI = 1.08-7.86). CONCLUSION The association between post-ICH LDL-C <1.8 mmol/L and recurrent ICH was predominantly observed in CAA patients and those with intrinsically low LDL-C (non-statin users). While statins can be safely prescribed in ICH survivors, LDL-C targets should be individualized and caution must be exercised in CAA patients.
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Affiliation(s)
- Tsz-Ching Lee
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - William Cy Leung
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Chun Ho
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Megan Wl Chiu
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Ian Yh Leung
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Yuen-Kwun Wong
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Liu Kc Roxanna
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Christopher Hf Sum
- Division of Neurosurgery, Department of Surgery, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - David Tw Lui
- Division of Endocrinology & Metabolism, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Raymond Tf Cheung
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Gilberto Kk Leung
- Division of Neurosurgery, Department of Surgery, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Koon-Ho Chan
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Kay-Cheong Teo
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Kui-Kai Lau
- Division of Neurology, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
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Gaist D, García Rodríguez LA, Hallas J, Hald SM, Möller S, Høyer BB, Selim M, Goldstein LB. Association of Statin Use With Risk of Stroke Recurrence After Intracerebral Hemorrhage. Neurology 2023; 101:e1793-e1806. [PMID: 37648526 PMCID: PMC10634647 DOI: 10.1212/wnl.0000000000207792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/12/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Survivors of spontaneous intracerebral hemorrhage (ICH) may have indications for statin therapy. The effect of statins on the risk of subsequent hemorrhagic and ischemic stroke (IS) in this setting is uncertain. We sought to determine the risk of any stroke (ischemic stroke, IS or recurrent ICH), IS, and recurrent ICH associated with statin use among ICH survivors. METHODS Using the Danish Stroke Registry, we identified all patients admitted to a hospital in Denmark (population 5.8 million) with a first-ever ICH between January 2003 and December 2021 who were aged 50 years or older and survived >30 days. Patients were followed up until August 2022. Within this cohort, we conducted 3 nested case-control analyses for any stroke, IS, and recurrent ICH. We matched controls for age, sex, time since first-ever ICH, and history of prior IS. The primary exposure was statin use before or on the date of subsequent stroke or the equivalent date in matched controls. Using conditional logistic regression, we calculated adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) for any stroke, IS, and recurrent ICH associated with statin exposure. RESULTS We identified 1,959 patients with any stroke (women 45.3%; mean [SD] age, 72.6 [9.7] years) who were matched to 7,400 controls; 1,073 patients with IS (women 42.0%; mean [SD] age, 72.4 [10.0] years) who were matched to 4,035 controls and 984 patients with recurrent ICH (women 48.7%; mean [SD] age, 72.7 [9.2] years) who were matched to 3,755 controls. Statin exposure was associated with a lower risk of both any stroke (cases 38.6%, controls 41.1%; aOR 0.88; 95% CI 0.78-0.99) and IS (cases 39.8%, controls 41.8%, aOR 0.79; 95% CI 0.67-0.92), but was not associated with recurrent ICH risk (cases 39.1%, controls 40.8%, aOR 1.05; 95% CI 0.88-1.24). DISCUSSION Exposure to statins was not associated with an increased risk of recurrent ICH but was associated with a lower risk of any stroke, largely due to a lower risk of IS. Confirmation of these findings in randomized trials is needed. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that statin use in patients with ICH is associated with a lower risk of any stroke and IS and not with increased risk of recurrent ICH.
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Affiliation(s)
- David Gaist
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington.
| | - Luis Alberto García Rodríguez
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jesper Hallas
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Stine Munk Hald
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sören Möller
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Birgit Bjerre Høyer
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Magdy Selim
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Larry B Goldstein
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
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Toffali M, Carbone F, Fainardi E, Morotti A, Montecucco F, Liberale L, Padovani A. Secondary prevention after intracerebral haemorrhage. Eur J Clin Invest 2023; 53:e13962. [PMID: 36721900 DOI: 10.1111/eci.13962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/22/2023] [Accepted: 01/28/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Intracerebral haemorrhage (ICH) has high mortality in the acute phase and poor functional outcome in the majority of survivors. ICH recurrence is a major determinant of long-term prognosis and is the most feared complication of antithrombotic treatment. On the other hand, ICH patients are at high risk of future ischaemic vascular events. METHODS This narrative review provides a critical analysis of the current knowledge on the topic. We performed a Pubmed search with the following terms 'intracerebral haemorrhage', 'stroke', 'outcome', 'secondary prevention', 'anticoagulation' and 'atrial fibrillation', including only English written studies with no time restrictions. RESULTS Blood pressure management is the cornerstone of secondary ICH prevention, regardless of ICH location or underlying cerebral small vessel disease. Resumption of antiplatelet and anticoagulation therapy is often challenging, with limited evidence from randomized trials. Clinical and imaging predictors can inform the stratification of ICH recurrence risk and might identify patients at very high probability of future haemorrhagic events. This narrative review provides a summary of the main diagnostic tools and therapeutic strategies available for secondary prevention in ICH survivors. CONCLUSION Appropriate recognition and treatment of modifiable risk factors for ICH recurrence might improve outcomes in ICH survivors. Ongoing randomized trials might provide novel insights and improve long-term management.
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Affiliation(s)
- Maddalena Toffali
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Andrea Morotti
- Department of Neurological Sciences and Vision, Neurology Unit, ASST Spedali Civili, Brescia, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genoa-Italian Cardiovascular Network, Genoa, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Department of Neurological Sciences and Vision, Neurology Unit, ASST Spedali Civili, Brescia, Italy
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