Drugs & Aging

, Volume 27, Issue 4, pp 311–325 | Cite as

Assessment and Management of Pressure Ulcers in the Elderly

Current Strategies
Review Article

Abstract

Pressure ulcers (pressure sores) continue to be a common health problem, particularly among the physically limited or bedridden elderly. The problem exists within the entire health framework, including hospitals, clinics, long-term care facilities and private homes.

For many elderly patients, pressure ulcers may become chronic for no apparent reason and remain so for prolonged periods, even for the remainder of the patient’s lifetime. A large number of grade 3 and 4 pressure ulcers become chronic wounds, and the afflicted patient may even die from an ulcer complication (sepsis or osteomyelitis).

The presence of a pressure ulcer constitutes a geriatric syndrome consisting of multifactorial pathological conditions. The accumulated effects of impairment due to immobility, nutritional deficiency and chronic diseases involving multiple systems predispose the aging skin of the elderly person to increasing vulnerability.

The assessment and management of a pressure ulcer requires a comprehensive and multidisciplinary approach in order to understand the patient with the ulcer. Factors to consider include the patient’s underlying pathologies (such as obstructive lung disease or peripheral vascular disease), severity of his or her primary illness (such as an infection or hip fracture), co-morbidities (such as dementia or diabetes mellitus), functional state (activities of daily living), nutritional status (swallowing difficulties), and degree of social and emotional support; focusing on just the wound itself is not enough. An understanding of the physiological and pathological processes of aging skin throws light on the aetiology and pathogenesis of the development of pressure ulcers in the elderly.

Each health discipline (nursing staff, aides, physician, dietitian, occupational and physical therapists, and social worker) has its own role to play in the assessment and management of the patient with a pressure ulcer. The goals of treating a pressure ulcer include avoiding any preventable contributing circumstances, such as immobilization after a hip fracture or acute infection. Once a pressure ulcer has developed, however, the goal is to heal it by optimizing regional blood flow (by use of a stent or vascular bypass surgery), managing underlying illnesses (such as diabetes, hypothyroidism or congestive heart failure) and providing adequate caloric and protein intake (whether through use of dietary supplements by mouth or by use of tube feeding). If the ulcer has become chronic, the ultimate goal changes from healing the wound to controlling symptoms (such as foul odour, pain, discomfort and infection) and preventing complications, thereby contributing to the patient’s overall well-being; providing support for the patient’s family is also important. Recent advances in wound dressings allow for greater control of symptoms and prevention of complications, and have also enabled the affected patient to be integrated more readily into the family setting and in the community at large. Ethical and end-of-life issues must also be addressed soon after the wound has become chronic.

This article discusses the pathogenesis of pressure ulcer development in the elderly in relation to concomitant diseases, risk factor assessment and the management of such ulcers.

Notes

Acknowledgements

No sources of funding were used to assist in the preparation of this review. The author has no conflicts of interest that are directly relevant to the content of this review. The author would like to thank Dr Sheva Mann, Professor Arnold Rosin and Iris Arad for their help in editing the article.

References

  1. 1.
    Allman RM, Goode PS, Burst N, et al. Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Adv Wound Care 1999; 12: 22–3PubMedGoogle Scholar
  2. 2.
    Smith DM. Pressure ulcers in the nursing home. Ann Intern Med 1995; 123: 433–42PubMedGoogle Scholar
  3. 3.
    Ferrell BA, Josephson K, Norvid P, et al. Pressure ulcers among patients admitted to home care. J Am Geriatr Soc 2000; 48(9): 1042–7PubMedGoogle Scholar
  4. 4.
    Smith DM. Pressure ulcers. In: Besdine RW, Rubinstein LZ, Sznder L, editors. The medical care of the nursing home resident. Philadelphia (PA): American College of Physician, 1996: 61–74Google Scholar
  5. 5.
    Lahmann NA, Halfens RJ, Dassen T. Pressure ulcers in German nursing homes and acute care hospitals: prevalence, frequency, and ulcer characteristics. Ostomy Wound Manage 2006 Feb; 52(2): 20–33PubMedGoogle Scholar
  6. 6.
    Margolis DJ, Bilker W, Knauss J, et al. The incidence and prevalence of pressure ulcers among elderly patients in general medical practice. Ann Epidemiol 2002 Jul; 12(5): 321–5PubMedCrossRefGoogle Scholar
  7. 7.
    Cassel CK. Successful aging: how increased life expectancy and medical advances are changing geriatric care. Geriatrics 2001; 56: 35–40PubMedGoogle Scholar
  8. 8.
    Teno JM, Mor V, DeSilva D, et al. Use of feeding tubes in nursing home residents with severe cognitive impairment. JAMA 2002; 287: 3211–2PubMedCrossRefGoogle Scholar
  9. 9.
    Stotts NA, Wu HS. Hospital recovery is facilitated by prevention of pressure ulcers in older adults. Crit Care Nurs Clin North Am 2007 Sep; 19(3): 269–75PubMedCrossRefGoogle Scholar
  10. 10.
    Lyder CH. Pressure ulcer prevention and management. JAMA 2003; 289: 223–6PubMedCrossRefGoogle Scholar
  11. 11.
    Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA 2006; 296: 974–84PubMedCrossRefGoogle Scholar
  12. 12.
    Baumgarten M, Margolis DJ, Orwig DL, et al. Pressure ulcer in elderly patients with hip fracture across the continuum of care. J Am Geriatr Soc 2009; 57: 863–70PubMedCrossRefGoogle Scholar
  13. 13.
    Jaul E. Setting up a dedicated pressure ulcer unit in a geriatric ward. J Wound Care 2003; 12(4): 131–3PubMedGoogle Scholar
  14. 14.
    Gracia AD, Thomas DR. Assessment and management of chronic pressure ulcers in the elderly. Med Clin North Am 2006; 90: 925–44CrossRefGoogle Scholar
  15. 15.
    Kayser-Jones JS, Beard RL, Sharpp TJ. Case study: dying with a stage IV pressure ulcer. Am J Nurs 2009 Jan; 109(1): 40–8PubMedCrossRefGoogle Scholar
  16. 16.
    Farage MA, Miller KW, Berardesca E, et al. Clinical implications of aging skin: cutaneous disorders in the elderly. Am J Clin Dermatol 2009; 10(2): 73–86PubMedCrossRefGoogle Scholar
  17. 17.
    Thomas DR. Age-related changes in wound healing. Drugs Aging 2001; 18(8): 607–20PubMedCrossRefGoogle Scholar
  18. 18.
    Thomas DR. Improving outcome of pressure ulcer with nutritional intervention: a review of the evidence. Nutrition 2001; 17: 121–5PubMedCrossRefGoogle Scholar
  19. 19.
    Kelley LS, Mobily PR. Iatrogenesis in the elderly: impaired skin integrity. J Gerontol Nurs 1991 Sep; 17(9): 24–9PubMedGoogle Scholar
  20. 20.
    Inouye SK, Studenski S, Tinetti Me, et al. Geriatric syndromes: clinical, research and policy implication of a Core Geriatric Concept. J Am Geriat Soc 2007; 55: 780–91PubMedCrossRefGoogle Scholar
  21. 21.
    Grey JE, Harding KG. The chronic non-healing wound: how to make it better. Hosp Med 1998; 59(7): 557–63PubMedGoogle Scholar
  22. 22.
    Takahashi PY, Cha SS, Kiemele LJ. Six-month mortality risks in long-term care residents with chronic ulcers. Int Wound J 2008 Dec; 5(5): 625–31PubMedCrossRefGoogle Scholar
  23. 23.
    Takahashi PY. Pressure ulcers and prognosis: candid conversations about healing and death. Geriatrics 2008 Nov; 63(11): 6–9PubMedGoogle Scholar
  24. 24.
    Thomas DR. Issues and dilemmas in the prevention and treatment of pressure ulcers. J Gerontol 2001; 56: 328–40CrossRefGoogle Scholar
  25. 25.
    Allman RM. Pressure ulcers among the elderly. N Engl J Med 1989; 320: 850–3PubMedCrossRefGoogle Scholar
  26. 26.
    Gerstein AD, Phillips TJ, Rogers GS, et al. Wound healing and aging. Dermatol Clin 1993 Oct; 11(4): 749–57PubMedGoogle Scholar
  27. 27.
    Van de Kerkhof PC, Van Bergen B, Spruijt K, et al. Age-related changes in wound healing. Clin Exp Dermatol 1994 Sep; 19(5): 369–74PubMedCrossRefGoogle Scholar
  28. 28.
    Doughty D. The process of wound healing: a nursing perspective. Prog Develop Ostomy Wound Care 1990; 2: 3–12Google Scholar
  29. 29.
    Enoch SE, Grey JE, Harding KG. Recent advances and emerging treatments. BMJ 2006; 332: 962–5PubMedCrossRefGoogle Scholar
  30. 30.
    Zuloff-Sani A, Kachel E, Frenkel O, et al. Macrophage suspension prepared from a blood unit for treatment of refractory human ulcers: transfusion and aphaeresis. Transfus Apher Sci 2004; 30: 163–7CrossRefGoogle Scholar
  31. 31.
    Ashcroff GS, Horan MA, Herrick SE, et al. Age-related differences in the temporal and spatial regulation of matrix metalloproteinase (MMPs) in normal skin and acute cutaneous wounds of healthy humans. Cell Tissue Res 1997; 290: 581–91CrossRefGoogle Scholar
  32. 32.
    Sager MA, Franke T, Inouye SK, et al. Functional outcome of acute medical illness and hospitalization in older persons. Arch Intern Med 1996; 156: 645–52PubMedCrossRefGoogle Scholar
  33. 33.
    Lindgren M, Unosson M, Kranz A-M, et al. Pressure ulcer risk factors in patients undergoing surgery. J Adv Nurs 2005; 50: 605–12PubMedCrossRefGoogle Scholar
  34. 34.
    Baumgarten M, Margolis D, Berlin JA, et al. Risk factors for pressure ulcers among hip fracture patients. Wound Repair Regen 2003; 11: 96–103PubMedCrossRefGoogle Scholar
  35. 35.
    Margolis DJ, Knauss J, Bilker W, et al. Medical conditions as risk factors for pressure ulcers in an outpatients setting. Age Aging 2003; 34: 259–64CrossRefGoogle Scholar
  36. 36.
    Stadelmann WK, Digenis AG, Tobin GR. Impediments to wound healing. Am J Surg 1998; 176: 36–47Google Scholar
  37. 37.
    Allman RM, Goode PS, Patrick MM, et al. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995 Mar 15; 273(11): 865–70PubMedCrossRefGoogle Scholar
  38. 38.
    Lindgren M, Unosson M, Fredrikson M, et al. Immobility: a major risk factor for development of pressure ulcers among adult hospitalized patients: a prospective study. Scand J Caring Sci 2004 Mar; 18(1): 57–64PubMedCrossRefGoogle Scholar
  39. 39.
    Allman RM. Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med 1997 Aug; 13(3): 421–36PubMedGoogle Scholar
  40. 40.
    Reed RL, Hepburn K, Adelson R, et al. Low serum albumin levels, confusion, and fecal incontinence: are these risk factors for pressure ulcers in mobility-impaired hospitalized adults? Gerontology 2003 Jul-Aug; 49(4): 255–9PubMedCrossRefGoogle Scholar
  41. 41.
    Norton D, McLaren R, Exton-Smith AN. An investigation of geriatric nursing problems in hospital. London: Churchill Livingstone, 1962: 193–224Google Scholar
  42. 42.
    Bergstrom N, Braden BJ, Laguzza A, et al. The Braden scale for predicting pressure sore risk. Nurs Res 1987; 36: 205–10PubMedCrossRefGoogle Scholar
  43. 43.
    Baxter S. Assessing pressure ulcer risk in long-term care using the Baxter S. Waterlow scale. Nurs Older People 2008 Sep; 20(7): 34–8PubMedGoogle Scholar
  44. 44.
    Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, et al. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs 2006 Apr; 54(1): 94–110PubMedCrossRefGoogle Scholar
  45. 45.
    Thomas DR. The role of nutrition in prevention and healing of pressure ulcers. Clin Geriatr Med 1997; 13: 497–510PubMedGoogle Scholar
  46. 46.
    Pinchcofsky-Devin GD, Kaminiski NW. Correlation of pressure sores and nutritional status. J Am Geriatric 1986; 34: 435–40Google Scholar
  47. 47.
    Manley MT. Incidence, contributory factors, and costs of pressure sores. S Afr Med J 1978; 53(6): 217–22PubMedGoogle Scholar
  48. 48.
    Visvanathan R. Under-nutrition in older people: a serious and growing global problem! J Postgrad Med 2003; 49: 352–60PubMedGoogle Scholar
  49. 49.
    Morley JE, Kraenzle D. Causes of weight loss in a community nursing home. J Am Geriatr Soc 1994; 42: 583–5PubMedGoogle Scholar
  50. 50.
    Mintzer J, Burns A. Anti-cholinergic side effect of drugs in elderly people. J R Soc 2000; 93: 457–62Google Scholar
  51. 51.
    White GN, O’Rourke F, Ong BS, et al. Dysphagia: causes, assessment, treatment, and management. Geriatrics 2008; 63(5): 15–20PubMedGoogle Scholar
  52. 52.
    Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr 1987; 11(1): 8–13PubMedCrossRefGoogle Scholar
  53. 53.
    Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at risk for malnutrition: the Mini Nutritional Assessment. Clin Geriatr Med 2002 Nov; 18(4): 737–57PubMedCrossRefGoogle Scholar
  54. 54.
    Covinsky KE, Covinsky MH, Palmer RM, et al. Serum albumin concentration and clinical assessments of nutritional status in hospitalized older people: different sides of different coins? J Am Geriatr Soc 2002; 50: 631–7PubMedCrossRefGoogle Scholar
  55. 55.
    Spilsbury K, Nelson A, Cullum N, et al. Pressure ulcers and their treatment and effects on quality of life: hospital in-patient perspectives. J Adv Nurs 2007; 57: 494–504PubMedCrossRefGoogle Scholar
  56. 56.
    Schim SM, Cullen B. Wound care at end of life. Nurs Clin North Am 2005; 40(2): 281–94PubMedCrossRefGoogle Scholar
  57. 57.
    Grey JE, Enoch S, Harding KG. Wound assessment: ABC of wound healing. BMJ 2006; 332: 285–8PubMedCrossRefGoogle Scholar
  58. 58.
    Izadi K, Ganchi P. Chronic wounds. Clin Plastic Surg 2005; 32: 209–22CrossRefGoogle Scholar
  59. 59.
    Black J, Baharestani M, Cuddigan J, et al. National Pressure Ulcer Advisory Panel’s updated pressure ulcer staging system. Dermatol Nurs 2007; 19: 343–9PubMedGoogle Scholar
  60. 60.
    Ankrom M, Bennett R, Sprigle S, et al. Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. Adv Skin Wound Care 2005; 18(1): 35–42PubMedCrossRefGoogle Scholar
  61. 61.
    Jaul E. Non-healing wounds: the geriatric approach. Arch Gerontol Geriatr 2009; 49: 224–6PubMedCrossRefGoogle Scholar
  62. 62.
    Grey JE, Enoch S, Harding KG. Pressure ulcers: ABC of wound healing. BMJ 2006; 332: 472–5PubMedCrossRefGoogle Scholar
  63. 63.
    Reuler JB, Cooney TG. The pressure sore: pathophysiology and principles of management. Ann Intern Med 1981; 94: 661–6PubMedGoogle Scholar
  64. 64.
    Reswick JB, Rogers J. Experience at Rancho los Amigos Hospital with devices and techniques to prevent pressure sores. In: Kennedi RM, Cowden JM, Scales JT, editors. Bedsore biomechanics. Baltimore (MD): University Park Press, 1976: 301–13Google Scholar
  65. 65.
    Bennet L, Kavner D, Lee BY, et al. Skin blood flow in seated geriatric patients. Arch Phys Med Rehabil 1981; 62: 392–8Google Scholar
  66. 66.
    Mayrovitz HN, Sims N. Biophysical effects of water and synthetic urine on skin. Adv Skin Wound Care 2001; 14(6): 302–8PubMedCrossRefGoogle Scholar
  67. 67.
    Nixon J, Cranny G, Iglesias C, et al. Randomized controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial. BMJ 2006; 332: 1413–5PubMedCrossRefGoogle Scholar
  68. 68.
    Berlowitz DR, Wilking SV. Risk factors for pressure sores: a comparison of cross-sectional and cohort-derived data. J Am Geriatr Soc 1989; 37: 1043–50PubMedGoogle Scholar
  69. 69.
    Bergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992; 40: 747–58PubMedGoogle Scholar
  70. 70.
    Brandeis GH, Morris JN, Nash DJ, et al. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990; 264: 2905–9PubMedCrossRefGoogle Scholar
  71. 71.
    Stratton RJ, Ek AC, Engfer M, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev 2005 Aug; 4(3): 422–50PubMedCrossRefGoogle Scholar
  72. 72.
    Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in the elderly. Cochrane Database Syst Rev 2005; (2): CD001880Google Scholar
  73. 73.
    Langer G, Schloemer G, Knerr A, et al. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev 2003; (4): CD003216Google Scholar
  74. 74.
    Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 2000; 342(3): 206–9PubMedCrossRefGoogle Scholar
  75. 75.
    Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999; 282(14): 1365–70PubMedCrossRefGoogle Scholar
  76. 76.
    Ciocon JO, Silverstone FA, Graver LM, et al. Tube feedings in elderly patients: indications, benefits, and complications. Arch Intern Med 1988; 148: 429–33PubMedCrossRefGoogle Scholar
  77. 77.
    Jaul E, Singer P, Calderon-Margalit R. Tube feeding in demented elderly with severe disabilities. Isr Med Assoc J 2006; 8(12): 870–4PubMedGoogle Scholar
  78. 78.
    Dwolatzky T, Berezovski S, Friedmann R, et al. A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people. Clin Nutr 2001; 20(6): 535–40PubMedCrossRefGoogle Scholar
  79. 79.
    Candy B, Sampson EL, Jones L. Enteral tube feeding in older people with advanced dementia: findings from a Cochrane systematic review. Int J Palliat Nurs 2009 Aug; 15(8): 396–404PubMedGoogle Scholar
  80. 80.
    Mehanna MH, Moledina J, Travis J, et al. Re-feeding syndrome: what it is and how to prevent and treat it. BMJ 2008; 336: 1495–8PubMedCrossRefGoogle Scholar
  81. 81.
    Clark M, Schols J, Benati G. Pressure ulcers and nutrition: a new European guideline. J Wound Care 2004; 13(7): 267–72PubMedGoogle Scholar
  82. 82.
    Goode PS, Thomas DR. Pressure ulcers: local wound care. Clin Geriatr Med 1997; 13: 543–52PubMedGoogle Scholar
  83. 83.
    Bale S. A guide to wound debridement. J Wound Care 1997; 4: 179–82Google Scholar
  84. 84.
    Moore Z, Cowman S. A systematic review of wound cleansing for pressure ulcers. J Clin Nurs 2008 Aug; 17(15): 1963–72PubMedCrossRefGoogle Scholar
  85. 85.
    Moore D. Hypochlorites: a review of the evidence. J Wound Care 1992; 1(4): 44–53Google Scholar
  86. 86.
    Thomas S, Loveless P. A comparative study of the properties of twelve hydrocolloid dressings. World Wide Wounds 1997 July [online]. Available from URL: http://www.worldwidewounds.com/1997/july/Thomas-Hydronet/hydronet.html [Accessed 2010 Jan 19]Google Scholar
  87. 87.
    Belmin J, Meaume S, Rabus MT, et al. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus non sequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc 2002; 50(2): 269–74PubMedCrossRefGoogle Scholar
  88. 88.
    Nixon J, McElvenny D, Mason S, et al. A sequential randomized controlled trial comparing a dry visco-elastic polymer pad and standard operating table mattress in the prevention of post-operative pressure sores. Int J Nurs Stud 1998; 35: 193–203PubMedCrossRefGoogle Scholar
  89. 89.
    Gray DG, Smith M. Comparison of a new foam mattress with the standard hospital mattress. J Wound Care 2000; 9:29–31PubMedGoogle Scholar
  90. 90.
    Hofman A, Geelkerken RH, Wille J, et al. Pressure sores and pressure-decreasing mattresses: controlled clinical trial. Lancet 1994; 343: 568–71PubMedCrossRefGoogle Scholar
  91. 91.
    Vanderwee K, Grypdonck MH, DeFloor T. Effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers. Age Ageing 2005; 34: 261–7PubMedCrossRefGoogle Scholar
  92. 92.
    Andersen KE, Jensen O, Kvorning SA, et al. Decubitus prophylaxis: a prospective trial on the efficiency of alternating-pressure air-mattresses and water-mattresses. Acta Derm Venerol 1983; 63: 227–30PubMedGoogle Scholar
  93. 93.
    Gordon H. Sugar and wound healing. Lancet 1985; 2: 663–4CrossRefGoogle Scholar
  94. 94.
    Frantz RA. Adjuvant therapy for ulcer care. Clin Geriatr Med 1997; 13(3): 553–62PubMedGoogle Scholar
  95. 95.
    Hess CL, Howard MA, Attinger CE. A review of mechanical adjuncts in wound healing: hydrotherapy, ultrasound, negative pressure therapy, hyperbaric oxygen, and electrostimulation. Ann Plast Surg 2003 Aug; 51(2): 210–8PubMedCrossRefGoogle Scholar
  96. 96.
    Sheffet A, Cytryn AS, Louria DB. Applying electric and electromagnetic energy as adjuvant treatment for pressure ulcers: a critical review. Ostomy Wound Manage 2000 Feb; 46(2): 28–33, 36-40, 42-4PubMedGoogle Scholar
  97. 97.
    Vikatmaa P, Juutilainen V, Kuukasjärvi V, et al. Negative pressure wound therapy: a systematic review on effectiveness and safety. Eur J Vasc Endovasc Surg 2008; 36(4): 438–48PubMedCrossRefGoogle Scholar
  98. 98.
    Kranke P, Bennett M, Roeckl-Wiedmann I, et al. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev 2004; (2): CD004123Google Scholar
  99. 99.
    Baba-Akbari Sari A, Flemming K, Cullum NA, et al. Therapeutic ultrasound for pressure ulcers. Cochrane Database Syst Rev 2006 Jul 19; (3): CD001275Google Scholar
  100. 100.
    Cullum N, Nelson EA, Flemming K, et al. Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy. Health Technol Assess 2001; 5(9): 1–221PubMedGoogle Scholar

Copyright information

© Adis Data Information BV 2010

Authors and Affiliations

  1. 1.Skilled Geriatric Nursing DepartmentHerzog HospitalJerusalemIsrael
  2. 2.Hebrew University Hadassah Medical SchoolJerusalemIsrael

Personalised recommendations