1
|
Marjanovic M, Stojanov V, Marjanovic I, Vukcevic-Milosevic G, Radivojevic N, Matic D. Age- and Gender-Related Differences in the Hemodynamic Status of Patients with Mild or Moderate Hypertension. Int J Gen Med 2022; 15:6043-6053. [PMID: 35818582 PMCID: PMC9270926 DOI: 10.2147/ijgm.s372092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/28/2022] [Indexed: 12/05/2022] Open
Abstract
Purpose The aim of this study was to use non-invasive impedance cardiography (ICG) to determine the hemodynamic status of patients with grade 1 and grade 2 hypertension in relation to gender and age. Patients and Methods We analyse prospectively collected data of 158 patients with grade 1 or grade 2 arterial hypertension. Patients were grouped according to age: 1) <50 years and 2) ≥50 years. Hemodynamic status of patients was assessed by using non-invasive ICG. For the purpose of this study two hemodynamic parameters were used: a) systemic vascular resistance index (SVRI) and b) left cardiac work index (LCWI). The primary endpoint was the hemodynamic status of patients. The secondary endpoint was hypertension-mediated organ damage. Results Increased SVRI was assessed in 80% of patients, more common in the ≥50 years group than in the <50 years group (88.5% vs 64.8%; p < 0.01). The occurrence of increased systemic vascular resistance correlates hierarchically with increasing age. Elevated LCWI (hypervolemia and/or hyperinotropy) was present in 63% of patients, more often in males than females (70.3% vs 57.1%; p < 0.05) as well in those <50 years than in older patients (70.4% vs 59.6%; p < 0.05). Patients with diabetes were less likely to have hypervolemia/hyperinotropy than those without diabetes (46.7% vs 67.2%; p < 0.01). Hypervolemia/hyperinotropy (46.7%) and hypovolemia/hypoinotropy (43.3%) were present in a similar percentage of diabetic patients. Left ventricular hypertrophy was found in 30 patients (19%). Patients with left ventricular hypertrophy were more commonly male (66.7% vs 42.2%; p = 0.016) and had increased systemic vascular resistance (96.7% vs 77.3%; p = 0.015) compared to the patients without left ventricular hypertrophy. Hypertensive retinopathy grade III was found in 14 patients (8.9%). Elevated daytime systolic pressure, diabetes and increased age are independent predictors of grade III hypertensive retinopathy. Patients with reduced renal function had higher mean systolic blood pressure (p < 0.05), were more commonly male (p < 0.01) and older (p < 0.01) than those without reduced renal function. Conclusion Although there are certain correlations between hemodynamic disorders and age and gender, specific hemodynamic status of an individual patient with hypertension cannot reliably be predicted on the basis of age and gender. The measurement of hemodynamic parameters by ICG can guide the clinician to select appropriate antihypertensive therapy to the patients’ hemodynamic pathophysiologic condition.
Collapse
Affiliation(s)
- Marija Marjanovic
- Clinic for Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Vesna Stojanov
- Clinic for Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivan Marjanovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Ophthalmology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Nenad Radivojevic
- Clinic for Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Dragan Matic
- Clinic for Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Correspondence: Dragan Matic, Clinic for Cardiology, University Clinical Centre of Serbia, Dr Koste Todorovića 8, Belgrade, 11000, Serbia, Tel +381 63 208 975, Email
| |
Collapse
|
2
|
Zhang J, Liang J, Zhang X, Su C, He J, Qiu Y, Zhou Z, Wang Z, Dong B, Tu Q, Xu S, Xia W, Tao J. Non-invasive Systemic Hemodynamic Index in Vascular Risk Stratification Tailored for Hypertensives. Front Cardiovasc Med 2021; 8:744349. [PMID: 34881303 PMCID: PMC8645861 DOI: 10.3389/fcvm.2021.744349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/18/2021] [Indexed: 11/26/2022] Open
Abstract
Vascular dysfunction is a key hallmark of hypertension and related cardiovascular outcomes. As a well-known hemodynamic disease, hypertension is characterized by abnormal ventricular-vascular interactions. Complementing non-invasive systemic hemodynamics in hypertensive vascular risk assessment is of promising significance. We aimed to investigate the effects of abnormal hemodynamic states other than elevated blood pressure on vascular damage and establish a united index of systemic hemodynamics for generalized vascular risk evaluation. Non-invasive systemic hemodynamics, assessed by impedance cardiography, was compared among blood pressure stages. Vascular function was evaluated by flow-mediated dilation (FMD) and brachial-ankle pulse wave velocity (baPWV). Systemic hemodynamics was obtained from a total of 88 enrollees with a mean (±SD) systolic blood pressure 140 (±17) mm Hg, and aged 17 to 91 years. Both stroke systemic vascular resistance index and left stroke work index exhibited a significant alteration among blood pressure stages (p < 0.001; p = 0.01, respectively), whereas heterogeneous hemodynamic and vascular function subsets existed within similar blood pressure. In addition, blood pressure categories failed to recognize between-group differences in endothelial dysfunction (p = 0.88) and arterial stiffness (p = 0.26). An increase in myocardial contractility and a parallel decrease in afterload was associated with the decline of vascular dysfunction. Systemic Hemodynamic Index (SHI), as a surrogate marker, demonstrated a significantly negative correlation with vascular damage index (VDI, r = −0.49, p < 0.001). These findings illustrate that systemic hemodynamics underlying hypertensives provides more vascular information. The SHI/VDI score may be a feasible tool for cardiovascular function assessment.
Collapse
Affiliation(s)
- Jianning Zhang
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiawen Liang
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoyu Zhang
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chen Su
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiang He
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yumin Qiu
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhe Zhou
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhichao Wang
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bing Dong
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiang Tu
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shiyue Xu
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wenhao Xia
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jun Tao
- Department of Hypertension and Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Disease, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation of Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
3
|
Glinz D, Bläsi C, Villiger A, Meienberg A, Socrates T, Pfister O, Mayr M, Haschke M, Vischer AS, Burkard T. Hemodynamic profiles in treatment-naive arterial hypertension and their clinical implication for treatment choice: an exploratory post hoc analysis. J Hypertens 2020; 39:1246-1253. [PMID: 33323914 DOI: 10.1097/hjh.0000000000002766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Noninvasive thoracic bioimpedance by the HOTMAN System estimates hemodynamic modulators and expresses them as hemodynamic profiles. Aims of this analysis were to describe hemodynamic profiles among treatment-naive hypertensive patients compared with normotensive controls and to investigate whether a hemodynamic-guided choice of therapy improves blood pressure (BP) control within 4 weeks. METHOD This exploratory post hoc analysis used data of a randomized parallel-group trial including 80 outpatients with newly diagnosed arterial hypertension (AHT), randomized to four antihypertensive first-line monotherapies, and 20 age-matched and sex-matched normotensive controls. Hemodynamic profiles were measured at baseline and after four weeks of treatment. On the basis of the hemodynamic profiles, the most appropriate pharmacological treatment was determined retrospectively and patients were categorised to have received concordant (ConTG) or discordant treatment (DisTG). RESULTS In the hypertensive group, hypervolemia with vasoconstriction was the predominant hemodynamic profile in 48% of patients and hypervolemia without vasoconstriction in 45%, compared with 15 and 50%, respectively, in the control group. After 4 weeks of treatment, the mean (±SD) 24-h BP was 129.9 (±11.0)/81.5 (±8.0) mmHg in the DisTG vs. 133.9 (±12.3)/84.0 (±9.1) mmHg in the ConTG (P = 0.158/0.222). The mean 24-h BP reductions were -9.7 (±10.1)/-5.0 (±6.2) mmHg in the DisTG and -12.4 (±14.8)/-6.9(±6.9) mmHg in the ConTG (P = 0.353/0.223). After 4 weeks of treatment, the BP control rate was 53.7% (43/80) among all, 55.7% (29/52) in the DisTG and 48% (12/25) in the ConTG (P = 0.628). CONCLUSION Our findings do not support the hypothesis that personalized treatment initiation based on hemodynamic profiles improves BP control in newly diagnosed hypertensive outpatients.
Collapse
Affiliation(s)
- Delphine Glinz
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel
| | - Claudia Bläsi
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel
| | - Andrea Villiger
- Department of Pharmacology, University Hospital Basel, Basel
| | - Andrea Meienberg
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel
| | - Thenral Socrates
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel
| | - Otmar Pfister
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Michael Mayr
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel
| | - Manuel Haschke
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital/University Hospital Bern, Bern
| | - Annina Salome Vischer
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel
| | - Thilo Burkard
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel.,Department of Cardiology, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
4
|
Silva Lopes B, Craveiro N, Firmino-Machado J, Ribeiro P, Castelo-Branco M. Hemodynamic differences among hypertensive patients with and without heart failure using impedance cardiography. Ther Adv Cardiovasc Dis 2019; 13:1753944719876517. [PMID: 31554488 PMCID: PMC6764032 DOI: 10.1177/1753944719876517] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Impedance cardiography is a reliable, well-tolerated, and non-invasive method used to obtain hemodynamic measurements and could potentially be useful in heart failure (HF) diagnosis, hemodynamic monitoring of critically ill patients, and help in the choice of antihypertensive therapy. The objective of this study was to determine the differences between hemodynamic parameters in a study population of hypertensive patients with and without HF, using impedance cardiography. Methods: A case-control study was designed and named the TARGET study. Participants were enrolled in two study groups: control group C, hypertensive patients without HF and the HF group, hypertensive patients with HF. A descriptive analysis was carried out to characterize the sample and differences in continuous variables were tested for statistical significance by independent sample t test. Results: The study included 102 hypertensive outpatients. The control group consisted of 77 individuals (58.4% males; mean age 63.9 ± 12.5 years old) and the HF group consisted of 25 individuals (44.0% males; mean age 74.2 ± 8.7 years old). The mean Cardiac Index (CI) was 2.70 ± 1.02 L.min.m−2 (2.89 ± 1.04 versus 2.12 ± 0.70; p < 0.001), mean Stroke Index (SI) was 35.5 ± 14.7 mL.m−2 (37.7 ± 15.2 versus 28.5 ± 10.8; p = 0.006), mean Ejection Phase Contractility Index (EPCI) was 33.7 ± 12.7 1000 s−2 (35.8 ± 13.1 versus 27.2 ± 9.2; p = 0.003), mean Inotropic State Index (ISI) was 74.3 ± 28.2 100 s−2 (78.8 ± 28.9 versus 60.6 ± 20.7; p = 0.005), and mean Left Stroke Work Index (LSWI) was 51.3 ± 23.1 g.min.m−2 (55.4 ± 23.5 versus 38.9 ± 16.6; p = 0.002). Conclusions: In this study, hypertensive patients with HF had significantly lower values of blood flow parameters, contractility, and left work indices compared with hypertensive patients without HF. These differences reflected the incorrect hemodynamic pattern (mostly hypodynamic) of these patients. Impedance cardiography (ICG) seems to be an adequate method to reflect these differences.
Collapse
Affiliation(s)
- Bruno Silva Lopes
- Tondela-Viseu Hospital Center, Physical and Rehabilitation Medicine Department, Avenida Rei D. Duarte, Viseu, 3504-509, Portugal
| | | | | | | | | |
Collapse
|
5
|
Farcas AD, Anton FP, Mocan M, Vida-Simiti LA. Hemodynamic monitoring using thoracic bioimpedance - an optimal solution for the treatment of hypertension. ACTA ACUST UNITED AC 2018; 91:474-478. [PMID: 30564027 PMCID: PMC6296714 DOI: 10.15386/cjmed-1085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 07/06/2018] [Accepted: 07/23/2018] [Indexed: 11/23/2022]
Abstract
Hypertension is a major issue of public health because of its increasing prevalence and multiple complications caused by failing to achieve an efficient blood pressure control. Considering hypertension as a hemodynamic disorder allows to prescribe a tailored therapy guided by individual hemodynamic parameters, therefore leading to an increased rate of control. We present the case of a 59 years old diabetic, dyslipidemic and obese male who, although treated with 5 classes of antihypertensive drugs had uncontrolled hypertension that caused left ventricular failure. Using the HOTMAN system of hemodynamic monitoring using thoracic electrical bioimpedance allowed a quick identification of the cause and guided the therapy, achieving blood pressure control after 5 days of treatment. Treating hypertension by identifying the underlying hemodynamic imbalance allows prescribing a tailored therapy and shortens the initiation and stabilization phases of treatment.
Collapse
Affiliation(s)
- Anca Daniela Farcas
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania. Internal Medicine Department, Emergency County Clinical Hospital Cluj-Napoca, Romania
| | - Florin Petru Anton
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania. Internal Medicine Department, Emergency County Clinical Hospital Cluj-Napoca, Romania
| | - Mihaela Mocan
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania. Internal Medicine Department, Emergency County Clinical Hospital Cluj-Napoca, Romania
| | - Luminita Animarie Vida-Simiti
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca, Romania. Internal Medicine Department, Emergency County Clinical Hospital Cluj-Napoca, Romania
| |
Collapse
|
6
|
Talvik A, Rebora P, Heinpalu-Kuum M, Salerno S, Miszkowska-Nagórna E, Liu X, Comotti T, Świerblewska E, Valsecchi MG, Fadl Elmula FEM, Larstorp AC, Narkiewicz K, Parati G, Laurent S, Viigimaa M. Non-invasive hemodynamic monitoring as a guide to drug treatment of uncontrolled hypertensive patients: effects on home blood pressure in the BEAUTY study. Blood Press 2018; 27:368-375. [DOI: 10.1080/08037051.2018.1505425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Anneli Talvik
- Tallinn University of Technology, North Estonia Medical Centre, Tallinn, Estonia
| | - Paola Rebora
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Marika Heinpalu-Kuum
- Tallinn University of Technology, North Estonia Medical Centre, Tallinn, Estonia
| | - Sabrina Salerno
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Department of Cardiology S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Italy
| | | | - Xiaoqiu Liu
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Department of Cardiology S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Italy
| | - Tommaso Comotti
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Department of Cardiology S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Italy
| | - Ewa Świerblewska
- Department of Hypertension and Diabetology Gdansk, Medical University of Gdansk, Poland
| | | | - Fadl Elmula M. Fadl Elmula
- Department of Cardiology Oslo, University of Oslo, Ullevaal Hospital, Section for Cardiovascular and Renal Research, Norway
| | - Anne Cecilie Larstorp
- Department of Cardiology Oslo, University of Oslo, Ullevaal Hospital, Section for Cardiovascular and Renal Research, Norway
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology Gdansk, Medical University of Gdansk, Poland
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Department of Cardiology S. Luca Hospital, IRCCS, Istituto Auxologico Italiano, Italy
| | - Stéphane Laurent
- Department of Pharmacology and INSERM U970, Hôpital Européen Georges Pompidou, Paris, France
| | - Margus Viigimaa
- Tallinn University of Technology, North Estonia Medical Centre, Tallinn, Estonia
| | | |
Collapse
|