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発熱(乳幼児と年長児の対応含む)(小児科)

著者: 中村元 小児科中村医院

監修: 五十嵐隆 国立成育医療研究センター

著者校正/監修レビュー済:2021/05/19
患者向け説明資料

概要・推奨   

  1. 3カ月以下の乳児の38以上の発熱は原則として入院である(推奨度1)
  1. 何か気になる患者は検査を行い、入院を考慮すべきである(推奨度1)
  1. 解熱薬は使用しないことが原則である。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
中村元 : 特に申告事項無し[2021年]
監修:五十嵐隆 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、以下について追加した。
  1. COVID-19など新しい感染症の流行により、小児科外来における発熱の対処も変化してきている。
  1. 鑑別診断において、患者情報(家庭状況、集団生活)の重要性が増している。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 発熱とは、同じ条件で測定して、平常より1℃以上高い状態をいう。予防接種法では37.5℃以上を発熱と定義している。38.0℃未満を微熱、39.0℃以上を高熱と呼ぶ。
  1. 発熱は、年齢が低いほど重篤な疾患が潜んでいる可能性が大きく、特に生後3カ月以内の乳児は原則として入院で経過観察すべきである[1]
  1. 発熱には3週間以上続く不明熱や、麻酔後に認められる悪性高血圧など重篤な疾患も含まれるが、ここでは主に外来で遭遇する小児の発熱のトリアージを説明する。
  1. 発熱は小児科外来で最も多い主訴の1つである[2][3]。原因は多岐にわたり、予後良後な疾患がほとんどだが、重篤な疾患を見逃さないように先入観を持たずに診療にあたらなくてはいけない。
  1. 受診前に患者情報を把握し、重篤な感染症の可能性を認めた場合には必要な感染防御処置をとる。
  1. 感染症(特にCOVID-19など)では理学所見だけでは鑑別診断が難しいことが多い。
  1. 発熱にかかわらず小児ではエビデンスの蓄積が乏しく敗血症でも決定的なガイドラインはない。ガイドラインにとらわれず診療することが重要である[4]
  1. 特に基礎疾患の有無を確認し、鑑別診断を進める必要がある[2]
  1. 体温は測定部位、測定方法、測定時間、測定環境によって差がある。日本では腋窩温を標準とする場合が多い。最近家庭でよく用いられている鼓膜体温計は測定誤差が大きく、乳幼児では不正確となりやすい。体温を問診する場合には、少なくとも測定部位、測定方法を確かめる。外来にて再検することが少なくない[5]
  1. 発熱に対する保護者の不安は大きく、十分な説明を行わなければならない。
 
異なる部位における正常体温

日本では一般的には腋窩温が普通に測定されているが、最近は種々の測定器具が販売されている。特に乳児では腋窩温の測定に時間がかかるため、鼓膜温計を使っている親が増えている。測定部位と体温のバラツキ(特に鼓膜温では測定方法が難しく測定ごとに1~2℃の差が出やすい)を確かめる必要がある。

問診・診察のポイント  
  1. 患児の月齢、年齢の確認が重要である。特に生後1カ月以内(新生児期)は重篤な疾患の場合が多く、入院を必要とする。炎症反応が認められなくても抗菌薬の投与を開始し、血液培養などの結果を待つ。

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文献 

著者: J A Lopez, K J McMillin, E A Tobias-Merrill, W M Chop
雑誌名: Postgrad Med. 1997 Feb;101(2):241-2, 245-52.
Abstract/Text Fever in infants and toddlers can portend a serious bacterial illness requiring a prompt medical response. When dealing with a febrile child between 1 and 36 months of age, physicians should consider toxicity, focal infections, age, and the results of a sepsis workup and then use a strategy based on the Rochester criteria to assess whether the patient is at low risk for a serious bacterial illness. On the basis of that determination, a plan for inpatient or outpatient management can be selected. Variations in treatment can reasonably be based on clinical judgment and physician and parent preferences.

PMID 9046938  Postgrad Med. 1997 Feb;101(2):241-2, 245-52.
著者: R Scott Watson, Joseph A Carcillo, Walter T Linde-Zwirble, Gilles Clermont, Jeffrey Lidicker, Derek C Angus
雑誌名: Am J Respir Crit Care Med. 2003 Mar 1;167(5):695-701. doi: 10.1164/rccm.200207-682OC. Epub 2002 Nov 14.
Abstract/Text Despite extensive research into the etiology and treatment of severe sepsis, little is known about its epidemiology in children. We sought to determine the age- and sex-adjusted incidence, outcome, and associated hospital costs of severe sepsis in United States children using 1995 hospital discharge and population data from seven states (24% of the United States population). Of 1,586,253 hospitalizations in children who were 19 years old or less, 9,675 met International Classification of Diseases, 9th revision, clinical modification-based severe sepsis criteria or 42,364 cases of pediatric severe sepsis per year nationally (0.56 cases per 1,000 population per year). The incidence was the highest in infants (5.16 per 1,000), fell dramatically in older children (0.20 per 1,000 in 10 to 14 year olds), and was 15% higher in boys than in girls (0.60 versus 0.52 per 1,000, p < 0.001). Hospital mortality was 10.3%, or 4,383 deaths nationally (6.2 per 100,000 population). Half of the cases had underlying disease (49.0%), and over one-fifth (22.9%) were low-birth-weight newborns. Respiratory infections (37%) and primary bacteremia (25%) were the most common infections. The mean length of stay and cost were 31 days and $40,600, respectively. Estimated annual total costs were 1.97 billion US dollars nationally. Severe sepsis is a significant health problem in children and is associated with the use of extensive healthcare resources. Infants are at highest risk, especially those with a low birth weight.

PMID 12433670  Am J Respir Crit Care Med. 2003 Mar 1;167(5):695-701. d・・・
著者: G J Browne, K Currow, J Rainbow
雑誌名: Emerg Med (Fremantle). 2001 Dec;13(4):426-35.
Abstract/Text
PMID 11903427  Emerg Med (Fremantle). 2001 Dec;13(4):426-35.
著者: J A Jaskiewicz, C A McCarthy, A C Richardson, K C White, D J Fisher, R Dagan, K R Powell
雑誌名: Pediatrics. 1994 Sep;94(3):390-6.
Abstract/Text OBJECTIVE: Prospective studies were conducted to test the hypothesis that infants unlikely to have serious bacterial infections (SBI) can be accurately identified by low risk criteria.
METHODS: Febrile infants (rectal T > or = 38 degrees C) < or = 60 days of age were considered at low risk for SBI if they met the following criteria: 1) appear well; 2) were previously healthy; 3) have no focal infection; 4) have WBC count 5.0-15.0 x 10(9) cells/L (5000-15,000/mm3), band form count < or = 1.5 x 10(9) cells/L (< or = 1500/mm3), < or = 10 WBC per high power field on microscopic examination of spun urine sediment, and < or = 5 WBC per high power field on microscopic examination of a stool smear (if diarrhea). The recommended evaluation included the culture of specimens of blood, cerebrospinal fluid, and urine for bacteria. Outcomes were determined. The negative predictive values of the low risk criteria for SBI and bacteremia were calculated.
RESULTS: Of 1057 eligible infants, 931 were well appearing, and, of these, 437 met the remaining low risk criteria. Five low risk infants had SBI including two infants with bacteremia. The negative predictive value of the low risk criteria was 98.9% (95% confidence interval, 97.2% to 99.6%) for SBI, and 99.5% (95% confidence interval, 98.2% to 99.9%) for bacteremia.
CONCLUSIONS: These data confirm the ability of the low risk criteria to identify infants unlikely to have SBI. Infants who meet the low risk criteria can be carefully observed without administering antimicrobial agents.

PMID 8065869  Pediatrics. 1994 Sep;94(3):390-6.
著者: M D Baker, L M Bell, J R Avner
雑誌名: Pediatrics. 1999 Mar;103(3):627-31.
Abstract/Text BACKGROUND: A previous study produced a protocol for outpatient management of febrile infants (FIs) judged to be at low risk for serious bacterial illness (SBI). This Philadelphia protocol demonstrated that 40% of FIs seen in the emergency department could be safely managed without antibiotics at home; and it was established by the emergency department staff as the standard of care at our institution.
OBJECTIVE: To determine 1) the actual practices of management of FIs 18 months after establishment of the Philadelphia protocol as the standard of care, and 2) the continued efficacy of noninvasive outpatient management of fever in FIs who, using the Philadelphia protocol, were identified as low risk for SBI.
DESIGN: Thirty-six-month consecutive cohort study.
SETTING: Urban pediatric emergency department.
PARTICIPANTS: Four hundred twenty-two infants, 29 to 60 days of age, with rectal temperatures >/=38.0 degrees C. Interventions. After a complete history taking, physical examination, and workup for SBI, infants were managed at the discretion of the attending physician in the emergency department. Subsequently, those management practices were reviewed and compliance with the Philadelphia protocol was evaluated. In addition, the overall efficacy and safety of that standard during 8 years of use was assessed.
RESULTS: Of the 422 FIs enrolled, 101 (24%) were prospectively identified as low risk for SBI, and safe for management without antibiotics. Twenty-eight (6%) FIs were managed out of accordance with the Philadelphia protocol. Seven were admitted out of accordance, 10 (2 with UTI) were discharged out of accordance, and 11 inpatients (1 with bacterial gastroenteritis) initially received no antibiotics out of accordance with the protocol. Physician failure to consider the results of the complete blood count or urinalysis accounted for errors involving FIs with SBI. None of the 43 FIs with SBI were identified by the Philadelphia protocol to be at low risk for SBI.
CONCLUSIONS: The Philadelphia protocol for outpatient management without antibiotics of FIs at low risk for SBI remains practical, reliable, and safe. Because breaches do occur, physicians must carefully scrutinize protocol compliance, especially with regard to the complete blood count and urinalysis.

PMID 10049967  Pediatrics. 1999 Mar;103(3):627-31.
著者: M N Baskin, E J O'Rourke, G R Fleisher
雑誌名: J Pediatr. 1992 Jan;120(1):22-7.
Abstract/Text STUDY OBJECTIVE: To determine the outcome of outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone.
DESIGN: Prospective consecutive cohort study.
SETTING: Urban emergency department.
PATIENTS: Five hundred three infants 28 to 89 days of age with temperatures greater than or equal to 38 degrees C who did not appear ill, had no source of fever detected on physical examination, had a peripheral leukocyte count less than 20 x 10(9) cells/L, had a cerebrospinal fluid leukocyte count less than 10 x 10(6)/L, did not have measurable urinary leukocyte esterase, and had a caretaker available by telephone. Follow-up was obtained for all but one patient (99.8%).
INTERVENTION: After blood, urine, and cerebrospinal fluid cultures had been obtained, the infants received 50 mg/kg intramuscularly administered ceftriaxone and were discharged home. The infants returned for evaluation and further intramuscular administration of ceftriaxone 24 hours later; telephone follow-up was conducted 2 and 7 days later.
RESULTS: Twenty-seven patients (5.4%) had a serious bacterial infection identified during follow-up; 476 (94.6%) did not. Of the 27 infants with serious bacterial infections, 9 (1.8%) had bacteremia (8 of these had occult bacteremia and 1 had bacteremia with a urinary tract infection), 8 (1.6%) had urinary tract infections without bacteremia, and 10 (2.0%) had bacterial gastroenteritis without bacteremia. Clinical screening criteria did not enable discrimination between infants with and those without serious bacterial infections. All infants with serious bacterial infections received an appropriate course of antimicrobial therapy and were well at follow-up. One infant had osteomyelitis diagnosed 1 week after entry into the study, received an appropriate course of intravenous antimicrobial therapy, and recovered fully.
CONCLUSIONS: After a full evaluation for sepsis, outpatient treatment of febrile infants with intramuscular administration of ceftriaxone pending culture results and adherence to a strict follow-up protocol is a successful alternative to hospital admission.

PMID 1731019  J Pediatr. 1992 Jan;120(1):22-7.
著者: Mario Gehri, Emmanuèle Guignard, Samira Radji Djahnine, Jocelyne Quillet Cotting, Corinne Yersin, Ermindo R Di Paolo, Jean-Daniel Krahenbuhl, André Pannatier
雑誌名: Pharm World Sci. 2005 Jun;27(3):254-7. doi: 10.1007/s11096-004-4771-x.
Abstract/Text OBJECTIVE: To determine how medical and nursing staff treat feverish children and compare the findings with their theoretical knowledge, evaluating how they might contribute to fever phobia in parents.
SETTING: Paediatric Emergency Department.
METHOD: In the first step, we analysed prospectively the files of all children having consulted the Paediatric Emergency Department with a history of fever or of body temperature above 38 degrees C during a 2-week period. The second step consisted of evaluating knowledge and perception of fever of doctors and nurses using a questionnaire.
MAIN OUTCOME MEASURES: Prospective study: final diagnosis (viral, non- invasive bacterial disorders, invasive bacterial disorders), site of measurement and average temperature. Evaluation of theoretical knowledge: definition of fever, site of measurement, evaluation of the child's clinical state, antipyretic drug choice.
RESULTS: A total of 114 children under 5 years of age were enrolled and 24 caregivers (12 doctors, 12 nurses, 90 of the staff) responded to the questionnaire. The results showed good consistency in theoretical knowledge, but an excessive fear about cerebral damage was also shown by doctors. This belief likely contributes to the transmission of fever phobia to parents. In contrast, analysis of children management showed that fever was often under-treated, especially by nurses and even more so by parents. Paracetamol remained the first-line antipyretic drug yet was often administered in insufficient doses. Non-steroidal anti-inflammatory drugs were seldom used, except by parents (16 of all the children). Contrary to literature, the favourite route of administration was the rectal one. Physical methods like sponging were largely used by nurses, despite the uncertainties in their real effectiveness and their known side-effects.
CONCLUSION: Our study showed that the management of feverish children was globally correct in the Paediatric Emergency Department, but several improvement measures have been taken (e.g. tables of normal and abnormal ranges of temperature, recommended temperature measurement techniques, dosage regimen of antipyretic drugs, guidelines to parents), justifying the implementation of a pharmaceutical follow-up.

PMID 16096897  Pharm World Sci. 2005 Jun;27(3):254-7. doi: 10.1007/s11・・・
著者: C Krantz
雑誌名: Pediatr Nurs. 2001 Nov-Dec;27(6):567-71.
Abstract/Text Misconceptions about childhood fevers heighten parents' concerns leading to frequent use of health care services. Designing, piloting, and evaluating nursing interventions to demystify parents' phobia of fevers are imperative. An evidence-based fever anticipatory guidance tool was designed to assist parents by: dispelling misconceptions, teaching proper care of their febrile child and appropriate use of antipyretics, and providing a list of serious signs that warrant medical attention. Concepts of the Health Belief Model (HBM) are applied to parent behavior to promote a greater understanding of their actions in the face of childhood fever. Informing consumers with accurate and consistent information has direct implications for changing practice in the hospital and community.

PMID 12024528  Pediatr Nurs. 2001 Nov-Dec;27(6):567-71.
著者: P Axelrod
雑誌名: Clin Infect Dis. 2000 Oct;31 Suppl 5:S224-9. doi: 10.1086/317516.
Abstract/Text Although physical methods of cooling are the treatment of choice for hyperthermia, their value in the treatment of fever remains uncertain. Methods involving convection and evaporation are more effective than those involving conduction for the treatment of hyperthermia. These same methods, combined with antipyretic medication, are preferable to immersion as treatment for fever in young children but are generally not practical in adults. Febrile children treated with tepid-water sponging plus antipyretic drugs are more uncomfortable that those treated with antipyretic drugs alone, although they exhibit slightly more rapid reductions in temperature. When febrile, seriously ill patients are externally cooled and are sedated or paralyzed with drugs that suppress shivering, they may have a more rapid reduction of fever and reduced energy expenditure than if treated with antipyretic drugs alone. A risk/benefit assessment of the consequences of such treatment is not yet possible.

PMID 11113027  Clin Infect Dis. 2000 Oct;31 Suppl 5:S224-9. doi: 10.10・・・
著者: Hedva Tessler, Rafael Gorodischer, Joseph Press, Natalya Bilenko
雑誌名: Isr Med Assoc J. 2008 May;10(5):346-9.
Abstract/Text BACKGROUND: Parental fear and misconceptions about fever are widespread in western society. Ethnicity and sociodemographic factors have been suggested as contributing factors.
OBJECTIVES: To test the hypothesis that undue parental concern about fever is less in traditional than in western cultural-ethnic groups.
METHODS: Bedouin (traditional society) and Jewish (western society) parents of children aged 0-5 years with fever were interviewed in a pediatric emergency unit. Interviews were conducted in the parents' most fluent language (Arabic or Hebrew). A quantitative variable (a 9 item "fever phobia" scale) was constructed.
RESULTS: The parents of 101 Jewish and 100 Bedouin children were interviewed. More Bedouin parents were unemployed, had less formal education and had more and younger children than the Jewish parents. Parents in both groups expressed erroneous beliefs and practices about fever; quantitative but not qualitative differences in fever phobia variables were documented. Compared with their Jewish counterparts, more Bedouin parents believed that fever may cause brain damage and death, administered antipyretic medications for temperature < or = 38 degrees C and at excessive doses, and consulted a physician within 24 hours even when the child had no signs of illness other than fever (all Pvalues <0.001). The mean fever phobia score was higher in the Bedouin than in the Jewish group (P< 0.001). By multivariate analysis, only the cultural-ethnic origin correlated with fever phobia.
CONCLUSIONS: A higher degree of fever phobia was found among parents belonging to the traditional Bedouin group as compared to western society parents.

PMID 18605356  Isr Med Assoc J. 2008 May;10(5):346-9.
著者: B D Schmitt
雑誌名: Am J Dis Child. 1980 Feb;134(2):176-81.
Abstract/Text Eighty-one parents bringing their children to a hospital-based pediatric clinic were surveyed about their understanding of fever. Most parents were unduly worried about low-grade fever, with temperatures of 38.9 degrees C or less. Their overconcern was designated "fever phobia." Most parents (52%) believed that moderate fever with a temperature of 40 degrees C or less can cause serious neurological side-effects. Hence, most parents treated fever aggressively: 85% gave antipyretic medication before the temperature reached 38.9 degrees C and 68% sponged the child before the temperature reached 39.5 degrees C. A review of the literature showed that the only serious complications of fever were febrile status epilepticus and heat stroke, two rare entities. The great concern of parents about fever is not justified. Health education to counteract "fever phobia" should be a part of routine pediatric care.

PMID 7352443  Am J Dis Child. 1980 Feb;134(2):176-81.
著者: Martin G Betz, Anton F Grunfeld
雑誌名: Eur J Emerg Med. 2006 Jun;13(3):129-33. doi: 10.1097/01.mej.0000194401.15335.c7.
Abstract/Text OBJECTIVES: To investigate children's caregivers' attitudes towards fever in an emergency department setting.
METHODS: A 25-item questionnaire was formulated, on the basis of similar previous published surveys, for administration to a convenience sample of caregivers. It was administered by a medical translator after triage, before assessment by a physician. Most questions were multiple choice, a few open-ended.
RESULTS: Three hundred questionnaires were administered to caregivers and 264 were analyzed. A high proportion (82%) of caregivers professed to be 'very worried' about fever. Temperatures that were felt to require treatment were relatively low (one-third treating <37.9 degrees C), but many respondents measured body temperature at the axilla. Similar to previously published studies, the main specific concerns were possible central nervous system damage (24%), seizures (19%) and death (5%), although worries about discomfort and signs of serious illness were also expressed by a significant number of respondents (11%). Similar to older surveys, home treatment of fever was worrisome, with too-frequent dosing (acetaminophen CONCLUSIONS: We found high levels of anxiety among caregivers presenting to a hospital emergency department with a complaint of fever in a child. Many caregivers appear to confuse effects of fever with the harmful effects of hyperthermia. Aggressive and potentially dangerous home therapy and monitoring of fever is common among the caregivers surveyed.

PMID 16679875  Eur J Emerg Med. 2006 Jun;13(3):129-33. doi: 10.1097/01・・・
著者: Rie Sakai, Akihisa Okumura, Eiji Marui, Shinichi Niijima, Toshiaki Shimizu
雑誌名: Pediatr Int. 2012 Feb;54(1):39-44. doi: 10.1111/j.1442-200X.2011.03449.x. Epub 2011 Oct 30.
Abstract/Text BACKGROUND: Undue parental fear of fever in children was termed "fever phobia" by Schmitt following a survey in the USA in 1980. In 2000, Crocetti et al. conducted the same survey and concluded that fever phobia existed even 20 years later. In this study, we explore differences in fever phobia between these two US populations and a Japanese sample, and determine whether parents of a single child or those whose child was previously hospitalized or had a febrile seizure report greater anxiety about fever.
METHODS: A questionnaire was distributed to parents of children who visited a pediatric outpatient clinic in Juntendo University Nerima Hospital between 19 and 30 November 2007.
RESULTS: Data was obtained from 211 parents who agreed to participate in the study. Compared with much smaller proportions reported in the two previous studies, 62% of caregivers considered a temperature below 37.8°C to be a fever, although less than half of parents reported that they were "very worried" about fever. Over 90% identified doctors and nurses as their primary information source. In contrast to 7% of parents in the US studies, almost no parents reported that temperatures could rise to or above 43.3°C if fever was left untreated; however, 63% of parents stated that they would visit a hospital.
CONCLUSIONS: Fever phobia exists on both sides of the border, and while caregivers in Japan appear to have a more accurate understanding of fever, they are more likely to rely on health-care professionals to manage the condition.

© 2011 The Authors. Pediatrics International © 2011 Japan Pediatric Society.
PMID 21883684  Pediatr Int. 2012 Feb;54(1):39-44. doi: 10.1111/j.1442-・・・
著者: K Yamanishi, T Okuno, K Shiraki, M Takahashi, T Kondo, Y Asano, T Kurata
雑誌名: Lancet. 1988 May 14;1(8594):1065-7.
Abstract/Text A virus was isolated from the peripheral blood lymphocytes of patients with exanthem subitum, cultured successfully in cord blood lymphocytes, and shown to be antigenically related to human herpesvirus-6 (HHV-6). Morphological features, as studied by thin-section electronmicroscopy, resembled those of herpes group viruses. Convalescent-phase serum samples, tested against the new viral antigen and HHV-6 antigen, showed seroconversion. The results strongly suggest that the newly isolated virus is identical or closely related to HHV-6 and the causal agent for exanthem subitum.

PMID 2896909  Lancet. 1988 May 14;1(8594):1065-7.
著者: K Balachandra, P I Ayuthaya, W Auwanit, C Jayavasu, T Okuno, K Yamanishi, M Takahashi
雑誌名: Microbiol Immunol. 1989;33(6):515-8.
Abstract/Text The antibody prevalence to human herpesvirus 6 (HHV-6) was compared between pregnant women and control women of similar ages in Thailand. No significant difference was detected in the antibody positive rate and antibody titers between both groups. The antibody titers in sera collected from pregnant women at 1st and 3rd trimester remained unchanged. Next, the antibody prevalence in infants were examined and the positive rate decreased until 3 months and started to increase from 6 months after birth. The present results suggest that the reactivation of HHV-6 might not occur during pregnancy and this virus infects infants postnatally.

PMID 2549348  Microbiol Immunol. 1989;33(6):515-8.
著者: K Yamanishi, T Okuno
雑誌名: Nihon Rinsho. 1989 Feb;47(2):285-9.
Abstract/Text
PMID 2542647  Nihon Rinsho. 1989 Feb;47(2):285-9.

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