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1. Prevalence and Trajectories of Post-COVID-19 Neurological Manifestations: A Systematic Review and Meta-Analysis

Author

Giussani, G, Westenberg, E, Garcia-Azorin, D, Bianchi, E, Khan, A, Allegri, R, Atalar, A, Baykan, B, Crivelli, L, Fornari, A, Frontera, J, Guekht, A, Helbok, R, Hoo, F, Kivipelto, M, Leonardi, M, Lopez Rocha, A, Mangialasche, F, Marcassoli, A, Acarli, A, Ozge, A, Prasad, K, Prasad, M, Sviatskaia, E, Thakur, K, Vogrig, A, Leone, M, Winkler, A, Giussani G., Westenberg E., Garcia-Azorin D., Bianchi E., Khan A. H. K. Y., Allegri R. F., Atalar A. C., Baykan B., Crivelli L., Fornari A., Frontera J. A., Guekht A., Helbok R., Hoo F. K., Kivipelto M., Leonardi M., Lopez Rocha A. S., Mangialasche F., Marcassoli A., Acarli A. N. O., Ozge A., Prasad K., Prasad M., Sviatskaia E., Thakur K., Vogrig A., Leone M. A., Winkler A. S., Giussani, G, Westenberg, E, Garcia-Azorin, D, Bianchi, E, Khan, A, Allegri, R, Atalar, A, Baykan, B, Crivelli, L, Fornari, A, Frontera, J, Guekht, A, Helbok, R, Hoo, F, Kivipelto, M, Leonardi, M, Lopez Rocha, A, Mangialasche, F, Marcassoli, A, Acarli, A, Ozge, A, Prasad, K, Prasad, M, Sviatskaia, E, Thakur, K, Vogrig, A, Leone, M, Winkler, A, Giussani G., Westenberg E., Garcia-Azorin D., Bianchi E., Khan A. H. K. Y., Allegri R. F., Atalar A. C., Baykan B., Crivelli L., Fornari A., Frontera J. A., Guekht A., Helbok R., Hoo F. K., Kivipelto M., Leonardi M., Lopez Rocha A. S., Mangialasche F., Marcassoli A., Acarli A. N. O., Ozge A., Prasad K., Prasad M., Sviatskaia E., Thakur K., Vogrig A., Leone M. A., and Winkler A. S.

Abstract

Introduction: The aim of this systematic review and meta-analysis was to evaluate the prevalence of thirteen neurological manifestations in people affected by COVID-19 during the acute phase and at 3, 6, 9 and 12-month followup time points. Methods: The study protocol was registered with PROSPERO (CRD42022325505). MEDLINE (PubMed), Embase, and the Cochrane Library were used as information sources. Eligible studies included original articles of cohort studies, case-control studies, cross-sectional studies, and case series with ≥5 subjects that reported the prevalence and type of neurological manifestations, with a minimum follow-up of 3 months after the acute phase of COVID-19 disease. Two independent reviewers screened studies from January 1, 2020, to June 16, 2022. The following manifestations were assessed: neuromuscular disorders, encephalopathy/altered mental status/delirium, movement disorders, dysautonomia, cerebrovascular disorders, cognitive impairment/dementia, sleep disorders, seizures, syncope/transient loss of consciousness, fatigue, gait disturbances, anosmia/hyposmia, and headache. The pooled prevalence and their 95% confidence intervals were calculated at the six pre-specified times. Results: 126 of 6,565 screened studies fulfilled the eligibility criteria, accounting for 1,542,300 subjects with COVID-19 disease. Of these, four studies only reported data on neurological conditions other than the 13 selected. The neurological disorders with the highest pooled prevalence estimates (per 100 subjects) during the acute phase of COVID-19 were anosmia/ hyposmia, fatigue, headache, encephalopathy, cognitive impairment, and cerebrovascular disease. At 3-month follow-up, the pooled prevalence of fatigue, cognitive impairment, and sleep disorders was still 20% and higher. At six- and 9-month follow-up, there was a tendency for fatigue, cognitive impairment, sleep disorders, anosmia/ hyposmia, and headache to further increase in prevalence. At 12-month follow-up

Published
2024

2. Research considerations for prospective studies of patients with coma and disorders of consciousness

Author

Tinti, L, Lawson, T, Molteni, E, Kondziella, D, Rass, V, Sharshar, T, Bodien, Y, Giacino, J, Mayer, S, Amiri, M, Muehlschlegel, S, Venkatasubba Rao, C, Vespa, P, Menon, D, Citerio, G, Helbok, R, Mcnett, M, Agarwal, S, Aiyagari, V, Akbari, Y, Albertson, A, Alexander, S, Alexandrov, A, Alkhachroum, A, Al-Mufti, F, Appavu, B, Gebrewold, M, Ayounb, M, Badenes, R, Bader, M, Badjiata, N, Balu, R, Barlow, B, Barra, M, Beekman, R, Beghi, E, Beqiri, E, Berlin, T, Bilotta, F, Bleck, T, Boerwinkle, V, Boly, M, Bonnel, A, Brazzi, L, Brown, E, Bulic, S, Caceres, E, Caceres, A, Cafiero, T, Carroll, E, Cediel, E, Chou, S, Claassen, J, Condie, C, Conti, A, Cosmas, K, Costa, P, Creutzfeldt, C, Dangayach, N, Dauri, M, Debicki, D, Degeorgia, M, Der-Nigoghossian, C, Desai, M, Dhar, R, Diringer, M, Durr, E, Edlow, B, Ercole, A, Estraneo, A, Falcone, G, Farrokh, S, Ferguson, A, Fernandez-Espejo, D, Fink, E, Fins, J, Foreman, B, Franchi, F, Frontera, J, Ganesan, R, Gaspard, N, Ghavam, A, Gibbons, C, Gilmore, E, Glustein, C, Gosseries, O, Green, T, Greer, D, Guanci, M, Gupta, D, Hahn, C, Hakimi, R, Hammond, F, Hanley, D, Hartings, J, Hassan, A, Hemphill, C, Da Cunha, A, Hinson, H, Hirsch, K, Hocker, S, Hu, P, Hu, X, Human, T, Hwang, D, Illes, J, Jaffa, M, James, M, Janas, A, Johnson, S, Jones, M, Jox, R, Kalanuria, A, Keller, E, Kennedy, L, Kennelly, M, Keogh, M, Kim, J, Kim, K, Kirsch, H, Kirschen, M, Ko, N, Kreitzer, N, Kromm, J, Kumar, A, Kurtz, P, Laureys, S, Lejeune, N, Lewis, A, Liang, J, Ling, G, Livesay, S, Luppi, A, Macdonald, J, Maddux, C, Mahanes, D, Mainali, S, Maldonado, N, Ribeiro, R, Mascia, L, Massimini, M, Mathur, R, Mccredie, V, Mejia-Mantilla, J, Mendoza, M, Meyfroidt, G, Mijangos, J, Moberg, D, Moheet, A, Montalenti, E, Monti, M, Morrison, C, Munar, M, Murtaugh, B, Naccache, L, Nagayama, M, Nairon, E, Nakagawa, T, Naldi, A, Narenthiran, G, Natarajan, G, Nemetsky, E, Newcombe, V, Nielsen, N, Niznick, N, Noronha-Falcão, F, Nyquist, P, Olson, D, Othman, M, Owen, A, Padayachy, L, Pajoumand, M, Park, S, Pergakis, M, Perry, H, Polizzotto, L, Pouratian, N, Spivack, M, Prisco, L, Provencio, J, Puglises, F, Puybasset, L, Rao, C, Rasmussen, L, Rasulo, F, Ray, B, Ricci, Z, Richardson, R, Shinotsuka, C, Robba, C, Robertson, C, Rohaut, B, Rolston, J, Romagnoli, S, Rosanova, M, Rosenthal, E, Rowe, S, Rubin, M, Russell, M, Silva, G, Sanz, L, Sarasso, S, Sarwal, A, Schiff, N, Schnakers, C, Seder, D, Shah, V, Shapiro-Rosenbaubm, A, Shapshak, A, Sharma, K, Shutter, L, Sitt, J, Slomine, B, Smetana, K, Smielewski, P, Smith, W, Stamatakis, E, Steinberg, A, Stevens, R, Suarez, J, Sung, G, Sussman, B, Taran, S, Mazzeo, A, Thibaut, A, Thompson, D, Threlkeld, Z, Toker, D, Torbey, M, Tosto, J, Trevick, S, Tsaousi, G, Turgeon, A, Udy, A, Varelas, P, Videtta, W, Voss, H, Vox, F, Wagner, A, Wahlster, S, Wainwright, M, Whyte, J, Witherspoon, B, Yakhkind, A, Yeager, S, Young, M, Zafar, S, Zafonte, R, Zahuranec, D, Zammit, C, Zhang, B, Ziai, W, Zimmerman, L, Zink, E, Tinti, Lorenzo, Lawson, Thomas, Molteni, Erika, Kondziella, Daniel, Rass, Verena, Sharshar, Tarek, Bodien, Yelena G, Giacino, Joseph T, Mayer, Stephan A, Amiri, Moshgan, Muehlschlegel, Susanne, Venkatasubba Rao, Chethan P, Vespa, Paul M, Menon, David K, Citerio, Giuseppe, Helbok, Raimund, McNett, Molly, Agarwal, Sachin, Aiyagari, Venkatesh, Akbari, Yama, Albertson, Asher, Alexander, Sheila, Alexandrov, Anne, Alkhachroum, Ayham, Al-Mufti, Fawaz, Amiri, Moshagan, Appavu, Brian, Gebrewold, Meron Awraris, Ayounb, Marc, Badenes, Rafael, Bader, Mary Kay, Badjiata, Neeraj, Balu, Ram, Barlow, Brooke, Barra, Megan, Beekman, Rachel, Beghi, Ettore, Beqiri, Erta, Berlin, Tracey, Bilotta, Federico, Bleck, Thomas, Bodien, Yelena, Boerwinkle, Varina, Boly, Melanie, Bonnel, Alexandra, Brazzi, Luca, Brown, Emery, Bulic, Sebina, Caceres, Eder, Caceres, Adrian, Cafiero, Tullio, Carroll, Elizabeth, Cediel, Emilio G, Chou, Sherry, Claassen, Jan, Condie, Chad, Conti, Alfredo, Cosmas, Katie, Costa, Paolo, Creutzfeldt, Claire, Dangayach, Neha, Dauri, Mario, Debicki, Derek, DeGeorgia, Michael, Der-Nigoghossian, Caroline, Desai, Masoom, Dhar, Rajat, Diringer, Michael, Durr, Emily, Edlow, Brian, Ercole, Ari, Estraneo, Anna, Falcone, Guido, Farrokh, Salia, Ferguson, Adam, Fernandez-Espejo, Davinia, Fink, Ericka, Fins, Joseph, Foreman, Brandon, Franchi, Federico, Frontera, Jennifer, Ganesan, Rishi, Gaspard, Nicolas, Ghavam, Ahmeneh, Giacino, Joseph, Gibbons, Christie, Gilmore, Emily, Glustein, Chavie, Gosseries, Olivia, Green, Theresa, Greer, David, Guanci, Mary, Gupta, Deepak, Hahn, Cecil, Hakimi, Ryan, Hammond, Flora, Hanley, Daniel F, Hartings, Jed, Hassan, Ahmed, Hemphill, Claude, Da Cunha, Arthur Henrique Galvão Bruno, Hinson, Holly, Hirsch, Karen, Hocker, Sarah, Hu, Peter, Hu, Xiao, Human, Theresa, Hwang, David, Illes, Judy, Jaffa, Matthew, James, Michael L, Janas, Anna, Johnson, Susan, Jones, Morgan, Jox, Ralf J, Kalanuria, Atul, Keller, Emanuela, Kennedy, Lori, Kennelly, Megan, Keogh, Maggie, Kim, Jenn, Kim, Keri, Kirsch, Hannah, Kirschen, Matthew, Ko, Nerissa, Kreitzer, Natalie, Kromm, Julie, Kumar, Abhay, Kurtz, Pedro, Laureys, Steven, Lejeune, Nicolas, Lewis, Ariane, Liang, John, Ling, Geoffrey, Livesay, Sarah, Luppi, Andrea, MacDonald, Jennifer, Maddux, Craig, Mahanes, Dea, Mainali, Shraddha, Maldonado, Nelson, Ribeiro, Rennan Martins, Mascia, Luciana, Massimini, Marcello, Mathur, Rohan, Mayer, Stephan, McCredie, Victoria, Mejia-Mantilla, Jorge, Mendoza, Michael, Menon, David, Meyfroidt, Geert, Mijangos, Julio, Moberg, Dick, Moheet, Asma, Montalenti, Elisa, Monti, Martin, Morrison, Chris, Munar, Marina, Murtaugh, Brooke, Naccache, Lionel, Nagayama, Masao, Nairon, Emerson, Nakagawa, Thomas, Naldi, Andrea, Narenthiran, Ganesalingam, Natarajan, Girija, Nemetsky, Esther, Newcombe, Virginia, Nielsen, Niklas, Niznick, Naomi, Noronha-Falcão, Filipa, Nyquist, Paul, Olson, DaiWai, Othman, Marwan, Owen, Adrian, Padayachy, Llewellyn, Pajoumand, Mehrnaz, Park, Soojin, Pergakis, Melissa, Perry, Heidi, Polizzotto, Len, Pouratian, Nader, Spivack, Marilyn Price, Prisco, Lara, Provencio, Javier, Puglises, Francesco, Puybasset, Louis, Rao, Chethan, Rasmussen, Lindsay, Rasulo, Frank, Ray, Bappaditya, Ricci, Zaccaria, Richardson, Risa, Shinotsuka, Cassia Righy, Robba, Chiara, Robertson, Courtney, Rohaut, Benjamin, Rolston, John, Romagnoli, Stefano, Rosanova, Mario, Rosenthal, Eric, Rowe, Shaun, Rubin, Michael, Russell, Mary Beth, Silva, Gisele Sampaio, Sanz, Leandro, Sarasso, Simone, Sarwal, Aarti, Schiff, Nicolas, Schnakers, Caroline, Seder, David, Shah, Vishank Arun, Shapiro-Rosenbaubm, Amy, Shapshak, Angela, Sharma, Kartavya, Sharma, Kumar Ajay, Shutter, Lori, Sitt, Jacobo, Slomine, Beth, Smetana, Keaton, Smielewski, Peter, Smith, Wade, Stamatakis, Emmanuel, Steinberg, Alexis, Stevens, Robert, Suarez, Jose, Sung, Gene, Sussman, Bethany, Taran, Shaurya, Mazzeo, Anna Teresa, Thibaut, Aurore, Thompson, David, Threlkeld, Zachary, Toker, Daniel, Torbey, Michel, Tosto, Jenna, Trevick, Stephen, Tsaousi, Georgia, Turgeon, Alexis, Udy, Andrew, Varelas, Panos, Vespa, Paul, Videtta, Walter, Voss, Henning, Vox, Ford, Wagner, Amy, Wahlster, Sarah, Wainwright, Mark, Whyte, John, Witherspoon, Briana, Yakhkind, Aleksandra (Sasha), Yeager, Susan, Young, Michael, Zafar, Sahar, Zafonte, Ross, Zahuranec, Darin, Zammit, Chris, Zhang, Bei, Ziai, Wendy, Zimmerman, Lara, Zink, Elizabeth, Tinti, L, Lawson, T, Molteni, E, Kondziella, D, Rass, V, Sharshar, T, Bodien, Y, Giacino, J, Mayer, S, Amiri, M, Muehlschlegel, S, Venkatasubba Rao, C, Vespa, P, Menon, D, Citerio, G, Helbok, R, Mcnett, M, Agarwal, S, Aiyagari, V, Akbari, Y, Albertson, A, Alexander, S, Alexandrov, A, Alkhachroum, A, Al-Mufti, F, Appavu, B, Gebrewold, M, Ayounb, M, Badenes, R, Bader, M, Badjiata, N, Balu, R, Barlow, B, Barra, M, Beekman, R, Beghi, E, Beqiri, E, Berlin, T, Bilotta, F, Bleck, T, Boerwinkle, V, Boly, M, Bonnel, A, Brazzi, L, Brown, E, Bulic, S, Caceres, E, Caceres, A, Cafiero, T, Carroll, E, Cediel, E, Chou, S, Claassen, J, Condie, C, Conti, A, Cosmas, K, Costa, P, Creutzfeldt, C, Dangayach, N, Dauri, M, Debicki, D, Degeorgia, M, Der-Nigoghossian, C, Desai, M, Dhar, R, Diringer, M, Durr, E, Edlow, B, Ercole, A, Estraneo, A, Falcone, G, Farrokh, S, Ferguson, A, Fernandez-Espejo, D, Fink, E, Fins, J, Foreman, B, Franchi, F, Frontera, J, Ganesan, R, Gaspard, N, Ghavam, A, Gibbons, C, Gilmore, E, Glustein, C, Gosseries, O, Green, T, Greer, D, Guanci, M, Gupta, D, Hahn, C, Hakimi, R, Hammond, F, Hanley, D, Hartings, J, Hassan, A, Hemphill, C, Da Cunha, A, Hinson, H, Hirsch, K, Hocker, S, Hu, P, Hu, X, Human, T, Hwang, D, Illes, J, Jaffa, M, James, M, Janas, A, Johnson, S, Jones, M, Jox, R, Kalanuria, A, Keller, E, Kennedy, L, Kennelly, M, Keogh, M, Kim, J, Kim, K, Kirsch, H, Kirschen, M, Ko, N, Kreitzer, N, Kromm, J, Kumar, A, Kurtz, P, Laureys, S, Lejeune, N, Lewis, A, Liang, J, Ling, G, Livesay, S, Luppi, A, Macdonald, J, Maddux, C, Mahanes, D, Mainali, S, Maldonado, N, Ribeiro, R, Mascia, L, Massimini, M, Mathur, R, Mccredie, V, Mejia-Mantilla, J, Mendoza, M, Meyfroidt, G, Mijangos, J, Moberg, D, Moheet, A, Montalenti, E, Monti, M, Morrison, C, Munar, M, Murtaugh, B, Naccache, L, Nagayama, M, Nairon, E, Nakagawa, T, Naldi, A, Narenthiran, G, Natarajan, G, Nemetsky, E, Newcombe, V, Nielsen, N, Niznick, N, Noronha-Falcão, F, Nyquist, P, Olson, D, Othman, M, Owen, A, Padayachy, L, Pajoumand, M, Park, S, Pergakis, M, Perry, H, Polizzotto, L, Pouratian, N, Spivack, M, Prisco, L, Provencio, J, Puglises, F, Puybasset, L, Rao, C, Rasmussen, L, Rasulo, F, Ray, B, Ricci, Z, Richardson, R, Shinotsuka, C, Robba, C, Robertson, C, Rohaut, B, Rolston, J, Romagnoli, S, Rosanova, M, Rosenthal, E, Rowe, S, Rubin, M, Russell, M, Silva, G, Sanz, L, Sarasso, S, Sarwal, A, Schiff, N, Schnakers, C, Seder, D, Shah, V, Shapiro-Rosenbaubm, A, Shapshak, A, Sharma, K, Shutter, L, Sitt, J, Slomine, B, Smetana, K, Smielewski, P, Smith, W, Stamatakis, E, Steinberg, A, Stevens, R, Suarez, J, Sung, G, Sussman, B, Taran, S, Mazzeo, A, Thibaut, A, Thompson, D, Threlkeld, Z, Toker, D, Torbey, M, Tosto, J, Trevick, S, Tsaousi, G, Turgeon, A, Udy, A, Varelas, P, Videtta, W, Voss, H, Vox, F, Wagner, A, Wahlster, S, Wainwright, M, Whyte, J, Witherspoon, B, Yakhkind, A, Yeager, S, Young, M, Zafar, S, Zafonte, R, Zahuranec, D, Zammit, C, Zhang, B, Ziai, W, Zimmerman, L, Zink, E, Tinti, Lorenzo, Lawson, Thomas, Molteni, Erika, Kondziella, Daniel, Rass, Verena, Sharshar, Tarek, Bodien, Yelena G, Giacino, Joseph T, Mayer, Stephan A, Amiri, Moshgan, Muehlschlegel, Susanne, Venkatasubba Rao, Chethan P, Vespa, Paul M, Menon, David K, Citerio, Giuseppe, Helbok, Raimund, McNett, Molly, Agarwal, Sachin, Aiyagari, Venkatesh, Akbari, Yama, Albertson, Asher, Alexander, Sheila, Alexandrov, Anne, Alkhachroum, Ayham, Al-Mufti, Fawaz, Amiri, Moshagan, Appavu, Brian, Gebrewold, Meron Awraris, Ayounb, Marc, Badenes, Rafael, Bader, Mary Kay, Badjiata, Neeraj, Balu, Ram, Barlow, Brooke, Barra, Megan, Beekman, Rachel, Beghi, Ettore, Beqiri, Erta, Berlin, Tracey, Bilotta, Federico, Bleck, Thomas, Bodien, Yelena, Boerwinkle, Varina, Boly, Melanie, Bonnel, Alexandra, Brazzi, Luca, Brown, Emery, Bulic, Sebina, Caceres, Eder, Caceres, Adrian, Cafiero, Tullio, Carroll, Elizabeth, Cediel, Emilio G, Chou, Sherry, Claassen, Jan, Condie, Chad, Conti, Alfredo, Cosmas, Katie, Costa, Paolo, Creutzfeldt, Claire, Dangayach, Neha, Dauri, Mario, Debicki, Derek, DeGeorgia, Michael, Der-Nigoghossian, Caroline, Desai, Masoom, Dhar, Rajat, Diringer, Michael, Durr, Emily, Edlow, Brian, Ercole, Ari, Estraneo, Anna, Falcone, Guido, Farrokh, Salia, Ferguson, Adam, Fernandez-Espejo, Davinia, Fink, Ericka, Fins, Joseph, Foreman, Brandon, Franchi, Federico, Frontera, Jennifer, Ganesan, Rishi, Gaspard, Nicolas, Ghavam, Ahmeneh, Giacino, Joseph, Gibbons, Christie, Gilmore, Emily, Glustein, Chavie, Gosseries, Olivia, Green, Theresa, Greer, David, Guanci, Mary, Gupta, Deepak, Hahn, Cecil, Hakimi, Ryan, Hammond, Flora, Hanley, Daniel F, Hartings, Jed, Hassan, Ahmed, Hemphill, Claude, Da Cunha, Arthur Henrique Galvão Bruno, Hinson, Holly, Hirsch, Karen, Hocker, Sarah, Hu, Peter, Hu, Xiao, Human, Theresa, Hwang, David, Illes, Judy, Jaffa, Matthew, James, Michael L, Janas, Anna, Johnson, Susan, Jones, Morgan, Jox, Ralf J, Kalanuria, Atul, Keller, Emanuela, Kennedy, Lori, Kennelly, Megan, Keogh, Maggie, Kim, Jenn, Kim, Keri, Kirsch, Hannah, Kirschen, Matthew, Ko, Nerissa, Kreitzer, Natalie, Kromm, Julie, Kumar, Abhay, Kurtz, Pedro, Laureys, Steven, Lejeune, Nicolas, Lewis, Ariane, Liang, John, Ling, Geoffrey, Livesay, Sarah, Luppi, Andrea, MacDonald, Jennifer, Maddux, Craig, Mahanes, Dea, Mainali, Shraddha, Maldonado, Nelson, Ribeiro, Rennan Martins, Mascia, Luciana, Massimini, Marcello, Mathur, Rohan, Mayer, Stephan, McCredie, Victoria, Mejia-Mantilla, Jorge, Mendoza, Michael, Menon, David, Meyfroidt, Geert, Mijangos, Julio, Moberg, Dick, Moheet, Asma, Montalenti, Elisa, Monti, Martin, Morrison, Chris, Munar, Marina, Murtaugh, Brooke, Naccache, Lionel, Nagayama, Masao, Nairon, Emerson, Nakagawa, Thomas, Naldi, Andrea, Narenthiran, Ganesalingam, Natarajan, Girija, Nemetsky, Esther, Newcombe, Virginia, Nielsen, Niklas, Niznick, Naomi, Noronha-Falcão, Filipa, Nyquist, Paul, Olson, DaiWai, Othman, Marwan, Owen, Adrian, Padayachy, Llewellyn, Pajoumand, Mehrnaz, Park, Soojin, Pergakis, Melissa, Perry, Heidi, Polizzotto, Len, Pouratian, Nader, Spivack, Marilyn Price, Prisco, Lara, Provencio, Javier, Puglises, Francesco, Puybasset, Louis, Rao, Chethan, Rasmussen, Lindsay, Rasulo, Frank, Ray, Bappaditya, Ricci, Zaccaria, Richardson, Risa, Shinotsuka, Cassia Righy, Robba, Chiara, Robertson, Courtney, Rohaut, Benjamin, Rolston, John, Romagnoli, Stefano, Rosanova, Mario, Rosenthal, Eric, Rowe, Shaun, Rubin, Michael, Russell, Mary Beth, Silva, Gisele Sampaio, Sanz, Leandro, Sarasso, Simone, Sarwal, Aarti, Schiff, Nicolas, Schnakers, Caroline, Seder, David, Shah, Vishank Arun, Shapiro-Rosenbaubm, Amy, Shapshak, Angela, Sharma, Kartavya, Sharma, Kumar Ajay, Shutter, Lori, Sitt, Jacobo, Slomine, Beth, Smetana, Keaton, Smielewski, Peter, Smith, Wade, Stamatakis, Emmanuel, Steinberg, Alexis, Stevens, Robert, Suarez, Jose, Sung, Gene, Sussman, Bethany, Taran, Shaurya, Mazzeo, Anna Teresa, Thibaut, Aurore, Thompson, David, Threlkeld, Zachary, Toker, Daniel, Torbey, Michel, Tosto, Jenna, Trevick, Stephen, Tsaousi, Georgia, Turgeon, Alexis, Udy, Andrew, Varelas, Panos, Vespa, Paul, Videtta, Walter, Voss, Henning, Vox, Ford, Wagner, Amy, Wahlster, Sarah, Wainwright, Mark, Whyte, John, Witherspoon, Briana, Yakhkind, Aleksandra (Sasha), Yeager, Susan, Young, Michael, Zafar, Sahar, Zafonte, Ross, Zahuranec, Darin, Zammit, Chris, Zhang, Bei, Ziai, Wendy, Zimmerman, Lara, and Zink, Elizabeth

Abstract

Disorders of consciousness are neurological conditions characterized by impaired arousal and awareness of self and environment. Behavioural responses are absent or are present but fluctuate. Disorders of consciousness are commonly encountered as a consequence of both acute and chronic brain injuries, yet reliable epidemiological estimates would require inclusive, operational definitions of the concept, as well as wider knowledge dissemination among involved professionals. Whereas several manifestations have been described, including coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state, a comprehensive neurobiological definition for disorders of consciousness is still lacking. The scientific literature is primarily observational, and studies-specific aetiologies lead to disorders of consciousness. Despite advances in these disease-related forms, there remains uncertainty about whether disorders of consciousness are a disease-agnostic unitary entity with a common mechanism, prognosis or treatment response paradigm. Our knowledge of disorders of consciousness has also been hampered by heterogeneity of study designs, variables, and outcomes, leading to results that are not comparable for evidence synthesis. The different backgrounds of professionals caring for patients with disorders of consciousness and the different goals at different stages of care could partly explain this variability. The Prospective Studies working group of the Neurocritical Care Society Curing Coma Campaign was established to create a platform for observational studies and future clinical trials on disorders of consciousness and coma across the continuum of care. In this narrative review, the author panel presents limitations of prior observational clinical research and outlines practical considerations for future investigations. A narrative review format was selected to ensure that the full breadth of study design considerations could be addressed and to facilit

Published
2024

3. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Hospital Course, Confounders, and Medications

Author

Barra, M, Zink, E, Bleck, T, Caceres, E, Farrokh, S, Foreman, B, Cediel, E, Hemphill, J, Nagayama, M, Olson, D, Suarez, J, Aiyagari, V, Akbari, Y, Al-Mufti, F, Alexander, S, Alexandrov, A, Alkhachroum, A, Amiri, M, Appavu, B, Gebre, M, Bader, M, Badjiata, N, Balu, R, Beekman, R, Beghi, E, Bell, K, Beqiri, E, Berlin, T, Bodien, Y, Boerwinkle, V, Boly, M, Bonnel, A, Brown, E, Carroll, E, Chou, S, Citerio, G, Classen, J, Condie, C, Cosmas, K, Creutzfeldt, C, Dangayach, N, Degeorgia, M, Der-Nigoghoss, C, Desai, M, Diringer, M, Dullaway, J, Edlow, B, Ercole, A, Estraneo, A, Falcone, G, Padayachy, L, Park, S, Pergakis, M, Polizzotto, L, Pouratian, N, Spivack, M, Prisco, L, Provencio, J, Puybasset, L, Rasmussen, L, Rass, V, Richardson, R, Shinots, C, Robba, C, Robertson, C, Rohaut, B, Rolston, J, Rosanova, M, Rosenthal, E, Russell, M, Silva, G, Sanz, L, Sarasso, S, Sarwal, A, Schiff, N, Schnakers, C, Seder, D, Shah, V, Shapiro-Rosen, A, Shapshak, A, Sharma, K, Sharshar, T, Shutter, L, Sitt, J, Slomine, B, Smielewski, P, Smith, W, Stamatakis, E, Steinberg, A, Ferioli, S, Fernandez-Esp, D, Fink, E, Fins, J, Frontera, J, Ganesan, R, Ghavam, A, Giacino, J, Gibbons, C, Gilmore, E, Gosseries, O, Green, T, Greer, D, Guanci, M, Hahn, C, Hakimi, R, Hanley, D, Hartings, J, Hassan, A, Hinson, H, Hirsch, K, Hocker, S, Hu, P, Hu, X, Human, T, Hwang, D, Illes, J, Jaffa, M, James, M, Janas, A, Jones, M, Keller, E, Keogh, M, Kim, J, Kim, K, Kirsch, H, Kirschen, M, Ko, N, Kondziella, D, Kreitzer, N, Stevens, R, Sussman, B, Taran, S, Thibaut, A, Threlkeld, Z, Tinti, L, Toker, D, Torbey, M, Trevick, S, Turgeon, A, Udy, A, Varelas, P, Venkatasubba, C, Vespa, P, Videtta, W, Voss, H, Vox, F, Wagner, A, Wainwright, M, Whyte, J, Witherspoon, B, Yakhind, A, Zafonte, R, Zahuranec, D, Zammit, C, Zhang, B, Ziai, W, Zimmerman, L, Kromm, J, Kumar, A, Kurtz, P, Laureys, S, Lawson, T, Lejeune, N, Lewis, A, Liang, J, Ling, G, Livesay, S, Luppi, A, Madden, L, Maddux, C, Mahanes, D, Mainali, S, Maldonado, N, Ribeiro, R, Massimini, M, Mayer, S, Mccredie, V, Mcnett, M, Mejia-Mantill, J, Menon, D, Meyfroidt, G, Mijangos, J, Moberg, D, Moheet, A, Molteni, E, Monti, M, Morrison, C, Muehlschlegel, S, Murtaugh, B, Naccache, L, Nairon, E, Natarajan, G, Newcombe, V, Nielsen, N, Noronha-Falc‹, F, Nyquist, P, Othman, M, Owen, A, Barra M. E., Zink E. K., Bleck T. P., Caceres E., Farrokh S., Foreman B., Cediel E. G., Hemphill J. C., Nagayama M., Olson D. W. M., Suarez J. I., Aiyagari V., Akbari Y., Al-Mufti F., Alexander S., Alexandrov A., Alkhachroum A., Amiri M., Appavu B., Gebre M. A., Bader M. K., Badjiata N., Balu R., Beekman R., Beghi E., Bell K., Beqiri E., Berlin T., Bodien Y., Boerwinkle V., Boly M., Bonnel A., Brown E., Carroll E., Chou S., Citerio G., Classen J., Condie C., Cosmas K., Creutzfeldt C., Dangayach N., DeGeorgia M., Der-Nigoghoss C., Desai M., Diringer M., Dullaway J., Edlow B., Ercole A., Estraneo A., Falcone G., Padayachy L., Park S., Pergakis M., Polizzotto L., Pouratian N., Spivack M. P., Prisco L., Provencio J., Puybasset L., Rasmussen L., Rass V., Richardson R., Shinots C. R., Robba C., Robertson C., Rohaut B., Rolston J., Rosanova M., Rosenthal E., Russell M. B., Silva G. S., Sanz L., Sarasso S., Sarwal A., Schiff N., Schnakers C., Seder D., Shah V. A., Shapiro-Rosen A., Shapshak A., Sharma K., Sharshar T., Shutter L., Sitt J., Slomine B., Smielewski P., Smith W., Stamatakis E., Steinberg A., Ferioli S., Fernandez-Esp D., Fink E., Fins J., Frontera J., Ganesan R., Ghavam A., Giacino J., Gibbons C., Gilmore E., Gosseries O., Green T., Greer D., Guanci M., Hahn C., Hakimi R., Hanley D. F., Hartings J., Hassan A., Hinson H., Hirsch K., Hocker S., Hu P., Hu X., Human T., Hwang D., Illes J., Jaffa M., James M. L., Janas A., Jones M., Keller E., Keogh M., Kim J., Kim K., Kirsch H., Kirschen M., Ko N., Kondziella D., Kreitzer N., Stevens R., Sussman B., Taran S., Thibaut A., Threlkeld Z., Tinti L., Toker D., Torbey M., Trevick S., Turgeon A., Udy A., Varelas P., Venkatasubba C., Vespa P., Videtta W., Voss H., Vox F., Wagner A., Wainwright M., Whyte J., Witherspoon B., Yakhind A., Zafonte R., Zahuranec D., Zammit C., Zhang B., Ziai W., Zimmerman L., Kromm J., Kumar A., Kurtz P., Laureys S., Lawson T., Lejeune N., Lewis A., Liang J., Ling G., Livesay S., Luppi A., Madden L., Maddux C., Mahanes D., Mainali S., Maldonado N., Ribeiro R. M., Massimini M., Mayer S., McCredie V., McNett M., Mejia-Mantill J., Menon D., Meyfroidt G., Mijangos J., Moberg D., Moheet A., Molteni E., Monti M., Morrison C., Muehlschlegel S., Murtaugh B., Naccache L., Nairon E., Natarajan G., Newcombe V., Nielsen N., Noronha-Falc‹ F., Nyquist P., Othman M., Owen A., Barra, M, Zink, E, Bleck, T, Caceres, E, Farrokh, S, Foreman, B, Cediel, E, Hemphill, J, Nagayama, M, Olson, D, Suarez, J, Aiyagari, V, Akbari, Y, Al-Mufti, F, Alexander, S, Alexandrov, A, Alkhachroum, A, Amiri, M, Appavu, B, Gebre, M, Bader, M, Badjiata, N, Balu, R, Beekman, R, Beghi, E, Bell, K, Beqiri, E, Berlin, T, Bodien, Y, Boerwinkle, V, Boly, M, Bonnel, A, Brown, E, Carroll, E, Chou, S, Citerio, G, Classen, J, Condie, C, Cosmas, K, Creutzfeldt, C, Dangayach, N, Degeorgia, M, Der-Nigoghoss, C, Desai, M, Diringer, M, Dullaway, J, Edlow, B, Ercole, A, Estraneo, A, Falcone, G, Padayachy, L, Park, S, Pergakis, M, Polizzotto, L, Pouratian, N, Spivack, M, Prisco, L, Provencio, J, Puybasset, L, Rasmussen, L, Rass, V, Richardson, R, Shinots, C, Robba, C, Robertson, C, Rohaut, B, Rolston, J, Rosanova, M, Rosenthal, E, Russell, M, Silva, G, Sanz, L, Sarasso, S, Sarwal, A, Schiff, N, Schnakers, C, Seder, D, Shah, V, Shapiro-Rosen, A, Shapshak, A, Sharma, K, Sharshar, T, Shutter, L, Sitt, J, Slomine, B, Smielewski, P, Smith, W, Stamatakis, E, Steinberg, A, Ferioli, S, Fernandez-Esp, D, Fink, E, Fins, J, Frontera, J, Ganesan, R, Ghavam, A, Giacino, J, Gibbons, C, Gilmore, E, Gosseries, O, Green, T, Greer, D, Guanci, M, Hahn, C, Hakimi, R, Hanley, D, Hartings, J, Hassan, A, Hinson, H, Hirsch, K, Hocker, S, Hu, P, Hu, X, Human, T, Hwang, D, Illes, J, Jaffa, M, James, M, Janas, A, Jones, M, Keller, E, Keogh, M, Kim, J, Kim, K, Kirsch, H, Kirschen, M, Ko, N, Kondziella, D, Kreitzer, N, Stevens, R, Sussman, B, Taran, S, Thibaut, A, Threlkeld, Z, Tinti, L, Toker, D, Torbey, M, Trevick, S, Turgeon, A, Udy, A, Varelas, P, Venkatasubba, C, Vespa, P, Videtta, W, Voss, H, Vox, F, Wagner, A, Wainwright, M, Whyte, J, Witherspoon, B, Yakhind, A, Zafonte, R, Zahuranec, D, Zammit, C, Zhang, B, Ziai, W, Zimmerman, L, Kromm, J, Kumar, A, Kurtz, P, Laureys, S, Lawson, T, Lejeune, N, Lewis, A, Liang, J, Ling, G, Livesay, S, Luppi, A, Madden, L, Maddux, C, Mahanes, D, Mainali, S, Maldonado, N, Ribeiro, R, Massimini, M, Mayer, S, Mccredie, V, Mcnett, M, Mejia-Mantill, J, Menon, D, Meyfroidt, G, Mijangos, J, Moberg, D, Moheet, A, Molteni, E, Monti, M, Morrison, C, Muehlschlegel, S, Murtaugh, B, Naccache, L, Nairon, E, Natarajan, G, Newcombe, V, Nielsen, N, Noronha-Falc‹, F, Nyquist, P, Othman, M, Owen, A, Barra M. E., Zink E. K., Bleck T. P., Caceres E., Farrokh S., Foreman B., Cediel E. G., Hemphill J. C., Nagayama M., Olson D. W. M., Suarez J. I., Aiyagari V., Akbari Y., Al-Mufti F., Alexander S., Alexandrov A., Alkhachroum A., Amiri M., Appavu B., Gebre M. A., Bader M. K., Badjiata N., Balu R., Beekman R., Beghi E., Bell K., Beqiri E., Berlin T., Bodien Y., Boerwinkle V., Boly M., Bonnel A., Brown E., Carroll E., Chou S., Citerio G., Classen J., Condie C., Cosmas K., Creutzfeldt C., Dangayach N., DeGeorgia M., Der-Nigoghoss C., Desai M., Diringer M., Dullaway J., Edlow B., Ercole A., Estraneo A., Falcone G., Padayachy L., Park S., Pergakis M., Polizzotto L., Pouratian N., Spivack M. P., Prisco L., Provencio J., Puybasset L., Rasmussen L., Rass V., Richardson R., Shinots C. R., Robba C., Robertson C., Rohaut B., Rolston J., Rosanova M., Rosenthal E., Russell M. B., Silva G. S., Sanz L., Sarasso S., Sarwal A., Schiff N., Schnakers C., Seder D., Shah V. A., Shapiro-Rosen A., Shapshak A., Sharma K., Sharshar T., Shutter L., Sitt J., Slomine B., Smielewski P., Smith W., Stamatakis E., Steinberg A., Ferioli S., Fernandez-Esp D., Fink E., Fins J., Frontera J., Ganesan R., Ghavam A., Giacino J., Gibbons C., Gilmore E., Gosseries O., Green T., Greer D., Guanci M., Hahn C., Hakimi R., Hanley D. F., Hartings J., Hassan A., Hinson H., Hirsch K., Hocker S., Hu P., Hu X., Human T., Hwang D., Illes J., Jaffa M., James M. L., Janas A., Jones M., Keller E., Keogh M., Kim J., Kim K., Kirsch H., Kirschen M., Ko N., Kondziella D., Kreitzer N., Stevens R., Sussman B., Taran S., Thibaut A., Threlkeld Z., Tinti L., Toker D., Torbey M., Trevick S., Turgeon A., Udy A., Varelas P., Venkatasubba C., Vespa P., Videtta W., Voss H., Vox F., Wagner A., Wainwright M., Whyte J., Witherspoon B., Yakhind A., Zafonte R., Zahuranec D., Zammit C., Zhang B., Ziai W., Zimmerman L., Kromm J., Kumar A., Kurtz P., Laureys S., Lawson T., Lejeune N., Lewis A., Liang J., Ling G., Livesay S., Luppi A., Madden L., Maddux C., Mahanes D., Mainali S., Maldonado N., Ribeiro R. M., Massimini M., Mayer S., McCredie V., McNett M., Mejia-Mantill J., Menon D., Meyfroidt G., Mijangos J., Moberg D., Moheet A., Molteni E., Monti M., Morrison C., Muehlschlegel S., Murtaugh B., Naccache L., Nairon E., Natarajan G., Newcombe V., Nielsen N., Noronha-Falc‹ F., Nyquist P., Othman M., and Owen A.

Abstract

The convergence of an interdisciplinary team of neurocritical care specialists to organize the Curing Coma Campaign is the first effort of its kind to coordinate national and international research efforts aimed at a deeper understanding of disorders of consciousness (DoC). This process of understanding includes translational research from bench to bedside, descriptions of systems of care delivery, diagnosis, treatment, rehabilitation, and ethical frameworks. The description and measurement of varying confounding factors related to hospital care was thought to be critical in furthering meaningful research in patients with DoC. Interdisciplinary hospital care is inherently varied across geographical areas as well as community and academic medical centers. Access to monitoring technologies, specialist consultation (medical, nursing, pharmacy, respiratory, and rehabilitation), staffing resources, specialty intensive and acute care units, specialty medications and specific surgical, diagnostic and interventional procedures, and imaging is variable, and the impact on patient outcome in terms of DoC is largely unknown. The heterogeneity of causes in DoC is the source of some expected variability in care and treatment of patients, which necessitated the development of a common nomenclature and set of data elements for meaningful measurement across studies. Guideline adherence in hemorrhagic stroke and severe traumatic brain injury may also be variable due to moderate or low levels of evidence for many recommendations. This article outlines the process of the development of common data elements for hospital course, confounders, and medications to streamline definitions and variables to collect for clinical studies of DoC.

Published
2023

4. The Curing Coma Campaign International Survey on Coma Epidemiology, Evaluation, and Therapy (COME TOGETHER)

Author

Helbok, R, Rass, V, Beghi, E, Bodien, Y, Citerio, G, Giacino, J, Kondziella, D, Mayer, S, Menon, D, Sharshar, T, Stevens, R, Ulmer, H, Venkatasubba Rao, C, Vespa, P, McNett, M, Frontera, J, Helbok, R, Rass, V, Beghi, E, Bodien, Y, Citerio, G, Giacino, J, Kondziella, D, Mayer, S, Menon, D, Sharshar, T, Stevens, R, Ulmer, H, Venkatasubba Rao, C, Vespa, P, McNett, M, and Frontera, J

Abstract

Background Although coma is commonly encountered in critical care, worldwide variability exists in diagnosis and management practices. We aimed to assess variability in coma definitions, etiologies, treatment strategies, and attitudes toward prognosis. Methods As part of the Neurocritical Care Society Curing Coma Campaign, between September 2020 and January 2021, we conducted an anonymous, international, cross-sectional global survey of health care professionals caring for patients with coma and disorders of consciousness in the acute, subacute, or chronic setting. Survey responses were solicited by sequential emails distributed by international neuroscience societies and social media. Fleiss kappa values were calculated to assess agreement among respondents. Results The survey was completed by 258 health care professionals from 41 countries. Respondents predominantly were physicians (n = 213, 83%), were from the United States (n = 141, 55%), and represented academic centers (n = 231, 90%). Among eight predefined items, respondents identified the following cardinal features, in various combinations, that must be present to define coma: absence of wakefulness (81%, kappa = 0.764); Glasgow Coma Score (GCS) <= 8 (64%, kappa = 0.588); failure to respond purposefully to visual, verbal, or tactile stimuli (60%, kappa = 0.552); and inability to follow commands (58%, kappa = 0.529). Reported etiologies of coma encountered included medically induced coma (24%), traumatic brain injury (24%), intracerebral hemorrhage (21%), and cardiac arrest/hypoxic-ischemic encephalopathy (11%). The most common clinical assessment tools used for coma included the GCS (94%) and neurological examination (78%). Sixty-six percent of respondents routinely performed sedation interruption, in the absence of contraindications, for clinical coma assessments in the intensive care unit. Advanced neurological assessment techniques in comatose patients included quantitative electroencephalography (EEG

Published
2022

8. Regional Brain Monitoring in the Neurocritical Care Unit

Author

Frontera, J, Ziai, W, O'Phelan, K, Leroux, P, Kirkpatrick, P, Diringer, M, Suarez, J, Citerio, G, Frontera J., Ziai W., O'Phelan K., Leroux P. D., Kirkpatrick P. J., Diringer M. N., Suarez J. I., Citerio Giuseppe, Frontera, J, Ziai, W, O'Phelan, K, Leroux, P, Kirkpatrick, P, Diringer, M, Suarez, J, Citerio, G, Frontera J., Ziai W., O'Phelan K., Leroux P. D., Kirkpatrick P. J., Diringer M. N., Suarez J. I., and Citerio Giuseppe

Abstract

Regional multimodality monitoring has evolved over the last several years as a tool to understand the mechanisms of brain injury and brain function at the cellular level. Multimodality monitoring offers an important augmentation to the clinical exam and is especially useful in comatose neurocritical care patients. Cerebral microdialysis, brain tissue oxygen monitoring, and cerebral blood flow monitoring all offer insight into permutations in brain chemistry and function that occur in the context of brain injury. These tools may allow for development of individual therapeutic strategies that are mechanistically driven and goal-directed. We present a summary of the discussions that took place during the Second Neurocritical Care Research Conference regarding regional brain monitoring.

Published
2015

9. Regional Brain Monitoring in the Neurocritical Care Unit

Author

Frontera J., Ziai W., O'Phelan K., Leroux P. D., Kirkpatrick P. J., Diringer M. N., Suarez J. I., Citerio Giuseppe, Frontera, J, Ziai, W, O'Phelan, K, Leroux, P, Kirkpatrick, P, Diringer, M, Suarez, J, and Citerio, G

Subjects
Brain Diseases, medicine.medical_specialty, Neurology, Critical Care, business.industry, Clinical exam, Neurointensive care, Context (language use), Brain monitoring, Critical Care and Intensive Care Medicine, Neurophysiological Monitoring, Oxygen monitoring, Cerebral blood flow, Humans, Medicine, Brain tissue oxygenation, Cerebral blood flow, Microdialysis, Neurocritical care, Neuromonitoring, Neurology (clinical), business, Intensive care medicine, Brain function
Abstract

Regional multimodality monitoring has evolved over the last several years as a tool to understand the mechanisms of brain injury and brain function at the cellular level. Multimodality monitoring offers an important augmentation to the clinical exam and is especially useful in comatose neurocritical care patients. Cerebral microdialysis, brain tissue oxygen monitoring, and cerebral blood flow monitoring all offer insight into permutations in brain chemistry and function that occur in the context of brain injury. These tools may allow for development of individual therapeutic strategies that are mechanistically driven and goal-directed. We present a summary of the discussions that took place during the Second Neurocritical Care Research Conference regarding regional brain monitoring.

Published
2015

11. Organ donation in adults: a critical care perspective

Author

Citerio, G, Cypel, M, Dobb, G, Dominguez Gil, B, Frontera, J, Greer, D, Manara, A, Shemie, S, Smith, M, Valenza, F, Wijdicks, E, CITERIO, GIUSEPPE, Wijdicks, E., Citerio, G, Cypel, M, Dobb, G, Dominguez Gil, B, Frontera, J, Greer, D, Manara, A, Shemie, S, Smith, M, Valenza, F, Wijdicks, E, CITERIO, GIUSEPPE, and Wijdicks, E.

Abstract

Purpose: The shortage of organs for transplantation is an important medical and societal problem because transplantation is often the best therapeutic option for end-stage organ failure. Methods: We review the potential deceased organ donation pathways in adult ICU practice, i.e. donation after brain death (DBD) and controlled donation after circulatory death (cDCD), which follows the planned withdrawal of life-sustaining treatments (WLST) and subsequent confirmation of death using cardiorespiratory criteria. Results: Strategies in the ICU to increase the number of organs available for transplantation are discussed. These include timely identification of the potential organ donor, optimization of the brain-dead donor by aggressive management of the physiological consequence of brain death, implementation of cDCD protocols, and the potential for ex vivo perfusion techniques. Conclusions: Organ donation should be offered as a routine component of the end-of-life care plan of every patient dying in the ICU where appropriate, and intensivists are the key professional in this process.

Published
2016

12. Manejo del dolor en la fibrodisplasia osificante progresiva

Author

Arén Frontera, J. J., López Garrido, J., Martínez Álvarez, L. J., Cordero López, J. L., and Ortiz Gómez, G. A.

Subjects
Treatment. Dexamethasone, Fibrodisplasia osificante progresiva, Pain crisis, Pregabalin, Tratamiento, Dexametasona, Crisis dolor, Pregabalina, Fibrodysplasia ossificans progressiva
Abstract

La fibrodisplasia osificante progresiva es una enfermedad de escasa prevalencia, 1 caso cada 2 millones de habitantes, hereditaria, severamente incapacitante, caracterizada por un proceso de osificación en músculos esqueléticos, fascias, tendones y ligamentos, sin tratamiento eficaz y que evoluciona por empujes, que se acompañan de dolor intenso, dando lugar a posteriori, después de varios empujes, a la instalación de dolor basal permanente. Analizamos las características más salientes de la enfermedad, su historia habitual, su forma de presentación, su evolución, el dolor acompañante y su tratamiento. Este se realiza para combatir el dolor, ya que no existe tratamiento en el momento actual, para la enfermedad de fondo, y será variable de acuerdo al momento evolutivo de la misma, comenzándose con paracetamol y AINE en etapas iniciales, para dar lugar luego al uso de opioides. En lo que se refiere a las crisis de dolor, secundarias a brotes de osificación heterotópicos, existe consenso actualmente en cuanto a la utilización de corticoides de alta potencia antiinflamatoria. Siendo el dolor un hecho relevante en esta patología, no hemos encontrado ninguna publicación que lo aborde específicamente, por lo cual entendemos oportuna esta comunicación. Presentamos el caso de persona de 27 años, sexo femenino, portadora de fibrodisplasia osificante progresiva, controlada desde hace años en nuestra Unidad por sus crisis dolorosas severas, así como también por dolor basal instalado en los últimos años. Se relata la presentación de la enfermedad, su evolución, su estado actual, los tratamientos que se han realizado, así como el manejo de su última, reciente y más severa crisis de dolor, en base a dexametasona en altas dosis, y al uso de pregabalina como coadyuvante. Se concluye con recomendaciones para tratar los empujes dolorosos, basadas en el uso de corticoides, así como el manejo del dolor basal siempre presente en estos pacientes, fundamentado en el uso de opioides. The fibrodysplasia ossificans progressiva is a disease of low prevalence, 1 case per 2 million inhabitants, hereditary, severely disabling, characterized by a process of ossification in skeletal muscles, fascia, tendons and ligaments, without effective treatment, evolving by thrusts which are accompanied by severe pain, resulting in a posteriori, after several thrusts, to installing permanent baseline pain. We analyze the most salient features of the disease, common history, its presentation, its evolution, the accompanying pain and its treatment. This is done to combat the pain, since there is no treatment at present, for the underlying disease, and will vary according to the time course of the same, beginning itself with paracetamol and NSAIDs in early stages, giving rise then to the use of opioids. In regard to pain crises, buds secondary heterotopic ossification, currently there is consensus regarding the use of high potency anti-inflammatory corticosteroids. With pain as a relevant in this disease, we found no publication that specifically addresses; therefore we consider this presentation timely. We report the case of a person of 27 years, female gender, fibrodysplasia ossificans progressiva carrier controlled for years in our unit, for its severe painful crises and baseline pain also installed in recent years. We report the presentation of the disease, its evolution, its current status, as well as treatments that have been made, well as the handling of her latest, recent and more severe pain thrust, based on high-dose dexamethasone, and the use of pregabalin as an adjuvant. It concludes with recommendations for treating painful crises, based on the use of corticosteroids, and baseline pain management always present in these patients, based on the use of opioids.

Published
2014

14. One-year monitoring of an oligonucleotide fluorescence in situ hybridization probe panel laboratory-developed test for bladder cancer detection

Author

Knuth, Shannon, primary, Tinawi-Aljundi, Rima, additional, King, Lauren, additional, Gildea, Michael, additional, Ng, Carrie, additional, Kahl, Joshua, additional, Dion, Jacqueline, additional, Young, Christopher, additional, Schervish, Edward, additional, Frontera, J. Rene, additional, Hafron, Jason, additional, Kernen, Kenneth, additional, Di Loreto, Robert, additional, and Aurich-Costa, Joan, additional

Published
2015
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16. MP69-20 HIGH PREDICTION RATE OF PROSTATE CANCER WITH MINIMALLY INVASIVE OLIGOFISH TEST

Author

Hafron, Jason, primary, Gildea, Mike, additional, Kahl, Josh, additional, Aljundi, Rima, additional, Day, Jackie, additional, Yumpo, Paola, additional, Morgan, Peggy, additional, Lutz, Michael, additional, Frontera, J. Rene, additional, Ng, Carrie, additional, Dion, Jacqueline, additional, Young, Chris, additional, Knuth, Shannon, additional, Di Loreto, Robert, additional, Kernen, Kenneth, additional, and Aurich-Costa, Joan, additional

Published
2014
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19. One-year monitoring of an oligonucleotide fluorescence in situ hybridization probe panel laboratory-developed test for bladder cancer detection.

Author

Tinawi-Aljundi, Rima, King, Lauren, Knuth, Shannon T., Gildea, Michael, Ng, Carrie, Kahl, Josh, Dion, Jacqueline, Young, Chris, Schervish, Edward W., Frontera, J. Rene, Hafron, Jason, Kernen, Kenneth M., Di Loreto, Robert, and Aurich-Costa, Joan

Subjects
OLIGONUCLEOTIDES, NUCLEOTIDES, CPG nucleotides, IN situ hybridization, BLADDER cancer
Abstract

Background: Previously, we had developed and manufactured an oligonucleotide fluorescence in situ hybridization (OligoFISH) probe panel based on the most clinically sensitive chromosomes found in a reference set of bladder carcinoma cases. The panel was clinically validated for use as a diagnostic and monitoring assay for bladder cancer, reaching 100% correlation with the results of the UroVysion test. After 1 year of using this probe panel, we present here the comparison of cytology, cystoscopy, and pathology findings to the OligoFISH probe panel results to calculate its clinical performance. Materials and methods: In order to calculate clinical performance, we compared the OligoFISH results to the cytology and cystoscopy/pathology findings for 147 initial diagnoses and 399 recurrence monitorings. Finally, we compared clinical performance to published values for the UroVysion test, including both low- and high-grade tumors. Results: Chromosomes 3, 6, 7, and 20 were highly involved in bladder carcinoma aneuploidy. At the initial diagnosis, we obtained 90.5% (95% confidence interval [CI]: 84.5%-94.7%) accuracy, 96.8% sensitivity (95% CI: 91.0%-99.3%), 79.2% specificity (95% CI: 65.9%-87.8%), 89.2% positive predictive value (PPV; 95% CI: 81.5%-94.5%), and 93.3% negative predictive value (NPV; 95% CI: 81.7%-97.3%). When monitoring for recurrence, we obtained 85.2% accuracy (95% CI: 81.3%-88.5%), 82.0% sensitivity (95% CI: 76.0%-87.1%), 88.4% specificity (95% CI: 83.2%-92.5%), 87.7% PPV (95% CI: 82.1%-92.0%), and 83.0% NPV (95% CI: 77.3%-87.8%). When looking at low- and high-grade tumors, the test showed 100% sensitivity for high-grade tumors (95% CI: 92.5%-100%) and 87.5% sensitivity (95% CI: 68.8%-95.5%) for low-grade tumors. All the clinical parameters for the OligoFISH panel were higher than the UroVysion test' s published performance. We found significantly higher clinical sensitivity and NPV at initial diagnosis and significantly higher specificity and PPV for recurrence. Conclusion: The OligoFISH probe panel is a fast, easy, and reproducible test for bladder cancer diagnosis and monitoring, with excellent clinical performance and utility. [ABSTRACT FROM AUTHOR]

Published
2015
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28. Seizures after Onyx Embolization for the Treatment of Cerebral Arteriovenous Malformation.

Author

DE LOS REYES, K., PATEL, A., DOSHI, A., EGOROVA, N., PANOV, F., BEDERSON, J. B., and FRONTERA, J. A.

Subjects
THERAPEUTIC embolization, ARTERIOVENOUS malformation, VASCULAR diseases, HEMORRHAGE, FEBRILE seizures
Abstract

Onyx embolization of cerebral arteriovenous malformations (AVM) has become increasingly common. We explored the risk of seizures after Onyx use. A retrospective review was conducted of 20 patients with supratentorial brain arteriovenous malformation (AVM) who received Onyx embolization between 2006 and 2009. Baseline demographics, clinical history, seizure history, AVM characteristics and treatment were compared between those who developed post-onyx seizure and those who did not. MRIs were reviewed for edema following Onyx treatment. Of 20 patients who underwent Onyx embolization, the initial AVM presentation was hemorrhage in 40% (N=8). The median number of embolizations was two (range 1-4) and the median final obliteration amount was 90% (range 50-100%). A history of seizure was present in 50% (N=10) of patients pre-embolization and 12 (60%) patients received seizure medications (treatment or prophylaxis) prior to embolization. Seizur post-Onyx embolization occurred in 45% (N=9). The median time to seizur post-Onyx was seven days (range 0.3-210). Four patients (20%) with seizures post-Onyx had no seizure history. Two of these patients (10%) had no other identifiable cause for seizure other than recent Onyx embolization. Seizures in these two patients occurred within 24 hours of Onyx administration. Among patients with post-Onyx seizures, there was a trend toward larger AVM size (P=0.091) and lower percent obliteration (P=0.062). Peri-AVM edema was present in 75% of MRIs performed within one month of Onyx treatment and may represent a possible etiology for seizures. New onset seizures post-Onyx embolization are not uncommon. Further study of seizure prevention is warranted. [ABSTRACT FROM AUTHOR]

Published
2011
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30. La enseñanza profesional obligatoria en el extranjero

Author

Frontera, J. M.

Subjects
Ciencias de la Educación, educación, enseñanza
Abstract

Que las masas obreras están realmente necesitadas de las modernas enseñanzas, es cosa ya fuera de duda. Ahora, ¿cómo suministrar al obrero y al empleado de mañana y al futuro modesto agricultor la preparación para el concienzudo ejercicio de su profesión, que no pueden adquirir actualmente ni en el taller, ni en la fábrica, ni en el mostrador, ni en el almacén, ni en el campo? Nos hallamos, insisto, ante uno de los problemas que más seriamente han preocupado a los pueblos cultos, frente a una de las cuestiones más debatidas en el extranjero y que reclaman la atención de nuestro país y una pronta solución, si tratamos de hacer algo, y algo eficaz, aprovechando las circunstancias presentes., Departamento de Ciencias de la Educación

Published
1916

32. The Curing Coma Campaign International Survey on Coma Epidemiology, Evaluation, and Therapy (COME TOGETHER)

Author

Helbok, Raimund, Rass, Verena, Beghi, Ettore, Bodien, Yelena G., Citerio, Giuseppe, Giacino, Joseph T., Kondziella, Daniel, Mayer, Stephan A., Menon, David, Sharshar, Tarek, Stevens, Robert D., Ulmer, Hanno, Venkatasubba Rao, Chethan P., Vespa, Paul, McNett, Molly, Frontera, Jennifer, Helbok, R, Rass, V, Beghi, E, Bodien, Y, Citerio, G, Giacino, J, Kondziella, D, Mayer, S, Menon, D, Sharshar, T, Stevens, R, Ulmer, H, Venkatasubba Rao, C, Vespa, P, Mcnett, M, and Frontera, J

Subjects
Disorders of consciousness, Critical care, Cross-Sectional Studies, Surveys and Questionnaires, Aftercare, Humans, Glasgow Coma Scale, Neurology (clinical), Coma, Critical Care and Intensive Care Medicine, Disorders of consciousne, Survey, Patient Discharge
Abstract

Background Although coma is commonly encountered in critical care, worldwide variability exists in diagnosis and management practices. We aimed to assess variability in coma definitions, etiologies, treatment strategies, and attitudes toward prognosis. Methods As part of the Neurocritical Care Society Curing Coma Campaign, between September 2020 and January 2021, we conducted an anonymous, international, cross-sectional global survey of health care professionals caring for patients with coma and disorders of consciousness in the acute, subacute, or chronic setting. Survey responses were solicited by sequential emails distributed by international neuroscience societies and social media. Fleiss κ values were calculated to assess agreement among respondents. Results The survey was completed by 258 health care professionals from 41 countries. Respondents predominantly were physicians (n = 213, 83%), were from the United States (n = 141, 55%), and represented academic centers (n = 231, 90%). Among eight predefined items, respondents identified the following cardinal features, in various combinations, that must be present to define coma: absence of wakefulness (81%, κ = 0.764); Glasgow Coma Score (GCS) ≤ 8 (64%, κ = 0.588); failure to respond purposefully to visual, verbal, or tactile stimuli (60%, κ = 0.552); and inability to follow commands (58%, κ = 0.529). Reported etiologies of coma encountered included medically induced coma (24%), traumatic brain injury (24%), intracerebral hemorrhage (21%), and cardiac arrest/hypoxic-ischemic encephalopathy (11%). The most common clinical assessment tools used for coma included the GCS (94%) and neurological examination (78%). Sixty-six percent of respondents routinely performed sedation interruption, in the absence of contraindications, for clinical coma assessments in the intensive care unit. Advanced neurological assessment techniques in comatose patients included quantitative electroencephalography (EEG)/connectivity analysis (16%), functional magnetic resonance imaging (7%), single-photon emission computerized tomography (6%), positron emission tomography (4%), invasive EEG (4%), and cerebral microdialysis (4%). The most commonly used neurostimulants included amantadine (51%), modafinil (37%), and methylphenidate (28%). The leading determinants for prognostication included etiology of coma, neurological examination findings, and neuroimaging. Fewer than 20% of respondents reported routine follow-up of coma survivors after hospital discharge; however, 86% indicated interest in future research initiatives that include postdischarge outcomes at six (85%) and 12 months (65%). Conclusions There is wide heterogeneity among health care professionals regarding the clinical definition of coma and limited routine use of advanced coma assessment techniques in acute care settings. Coma management practices vary across sites, and mechanisms for coordinated and sustained follow-up after acute treatment are inconsistent. There is an urgent need for the development of evidence-based guidelines and a collaborative, coordinated approach to advance both the science and the practice of coma management globally.

Published
2022

33. Organ donation in adults: a critical care perspective

Author

Jennifer A. Frontera, Sam D. Shemie, Franco Valenza, Beatriz Domínguez-Gil, Giuseppe Citerio, Marcelo Cypel, G. J. Dobb, Alex Manara, David M. Greer, Martin Smith, Eelco F. M. Wijdicks, Citerio, G, Cypel, M, Dobb, G, Dominguez Gil, B, Frontera, J, Greer, D, Manara, A, Shemie, S, Smith, M, Valenza, F, and Wijdicks, E

Subjects
Adult, Brain Death, medicine.medical_specialty, Tissue and Organ Procurement, Care perspective, Pain medicine, Economic shortage, Critical Care and Intensive Care Medicine, Organ donation, 03 medical and health sciences, 0302 clinical medicine, Intensive care, Anesthesiology, medicine, Humans, 030212 general & internal medicine, Intensive care medicine, Donation after circulatory death, Withholding Treatment, business.industry, 030208 emergency & critical care medicine, Heart Arrest, Donation after brain death, Transplantation, Intensive Care Units, surgical procedures, operative, business
Abstract

Purpose: The shortage of organs for transplantation is an important medical and societal problem because transplantation is often the best therapeutic option for end-stage organ failure. Methods: We review the potential deceased organ donation pathways in adult ICU practice, i.e. donation after brain death (DBD) and controlled donation after circulatory death (cDCD), which follows the planned withdrawal of life-sustaining treatments (WLST) and subsequent confirmation of death using cardiorespiratory criteria. Results: Strategies in the ICU to increase the number of organs available for transplantation are discussed. These include timely identification of the potential organ donor, optimization of the brain-dead donor by aggressive management of the physiological consequence of brain death, implementation of cDCD protocols, and the potential for ex vivo perfusion techniques. Conclusions: Organ donation should be offered as a routine component of the end-of-life care plan of every patient dying in the ICU where appropriate, and intensivists are the key professional in this process.

Published
2016

34. Corrigendum to "Global uncertainty in the diagnosis of neurological complications of SARS-CoV-2 infection by both neurologists and non-neurologists: An international inter-observer variability study" [Journal of the Neurological Sciences. 2023 Jun 15;449:120646].

Author

Tamborska AA, Wood GK, Westenberg E, Garcia-Azorin D, Webb G, Schiess N, Netravathi M, Baykan B, Dervaj R, Helbok R, Lant S, Özge A, Padovani A, Saylor D, Schmutzhard E, Easton A, Lilleker JB, Jackson T, Beghi E, Ellul MA, Frontera JA, Pollak T, Nicholson TR, Wood N, Thakur KT, Solomon T, Stark RJ, Winkler AS, and Michael BD

Published
2023
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35. Global uncertainty in the diagnosis of neurological complications of SARS-CoV-2 infection by both neurologists and non-neurologists: An international inter-observer variability study.

Author

Tamborska AA, Wood GK, Westenberg E, Garcia-Azorin D, Webb G, Schiess N, Netravathi M, Baykan B, Dervaj R, Helbok R, Lant S, Özge A, Padovani A, Saylor D, Schmutzhard E, Easton A, Lilleker JB, Jackson T, Beghi E, Ellul MA, Frontera JA, Pollak T, Nicholson TR, Wood N, Thakur KT, Solomon T, Stark RJ, Winkler AS, and Michael BD

Subjects
Humans, SARS-CoV-2, Observer Variation, Uncertainty, Headache diagnosis, Headache etiology, COVID-19 Testing, COVID-19 complications, COVID-19 diagnosis, Nervous System Diseases etiology, Nervous System Diseases complications, Encephalitis complications, Guillain-Barre Syndrome diagnosis, Guillain-Barre Syndrome complications
Abstract

Introduction: Uniform case definitions are required to ensure harmonised reporting of neurological syndromes associated with SARS-CoV-2. Moreover, it is unclear how clinicians perceive the relative importance of SARS-CoV-2 in neurological syndromes, which risks under- or over-reporting., Methods: We invited clinicians through global networks, including the World Federation of Neurology, to assess ten anonymised vignettes of SARS-CoV-2 neurological syndromes. Using standardised case definitions, clinicians assigned a diagnosis and ranked association with SARS-CoV-2. We compared diagnostic accuracy and assigned association ranks between different settings and specialties and calculated inter-rater agreement for case definitions as "poor" (κ ≤ 0.4), "moderate" or "good" (κ > 0.6)., Results: 1265 diagnoses were assigned by 146 participants from 45 countries on six continents. The highest correct proportion were cerebral venous sinus thrombosis (CVST, 95.8%), Guillain-Barré syndrome (GBS, 92.4%) and headache (91.6%) and the lowest encephalitis (72.8%), psychosis (53.8%) and encephalopathy (43.2%). Diagnostic accuracy was similar between neurologists and non-neurologists (median score 8 vs. 7/10, p = 0.1). Good inter-rater agreement was observed for five diagnoses: cranial neuropathy, headache, myelitis, CVST, and GBS and poor agreement for encephalopathy. In 13% of vignettes, clinicians incorrectly assigned lowest association ranks, regardless of setting and specialty., Conclusion: The case definitions can help with reporting of neurological complications of SARS-CoV-2, also in settings with few neurologists. However, encephalopathy, encephalitis, and psychosis were often misdiagnosed, and clinicians underestimated the association with SARS-CoV-2. Future work should refine the case definitions and provide training if global reporting of neurological syndromes associated with SARS-CoV-2 is to be robust., Competing Interests: Declaration of Competing Interest KTT is an external consultant at the World Health Organization and the Clinical Immunization Safety Assessment Committee, CDC. BDM is an external consultant at the World Health Organization., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Published
2023
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36. Acute Cytotoxic and Vasogenic Edema after Subarachnoid Hemorrhage: A Quantitative MRI Study.

Author

Weimer JM, Jones SE, and Frontera JA

Subjects
Adult, Aged, Brain Edema diagnostic imaging, Diffusion Magnetic Resonance Imaging methods, Female, Humans, Male, Middle Aged, Retrospective Studies, Subarachnoid Hemorrhage diagnostic imaging, Brain Edema etiology, Subarachnoid Hemorrhage complications
Abstract

Background and Purpose: The mechanism of early brain injury following subarachnoid hemorrhage is not well understood. We aimed to evaluate if cytotoxic and vasogenic edema are contributing factors., Materials and Methods: A retrospective analysis was conducted in patients with SAH undergoing diffusion-weighted MR imaging within 72 hours of onset. Apparent diffusion coefficient values derived from DWI were evaluated by using whole-brain histograms and 19 prespecified ROIs in patients with SAH and controls with normal findings on MRI. Cytotoxic edema observed outside the ROIs was assessed in patients with SAH. The average median ADC values were compared between patients with SAH and controls and patients with SAH with mild (Hunt and Hess 1-3) versus severe early brain injury (Hunt and Hess 4-5)., Results: We enrolled 33 patients with SAH and 66 controls. The overall average median whole-brain ADC was greater for patients with SAH (808 × 10 -6 mm 2 /s) compared with controls (788 × 10 -6 mm 2 /s, P < .001) and was higher in patients with SAH across ROIs after adjusting for age: cerebral gray matter (826 versus 803 × 10 -6 mm 2 /s, P = .059), cerebral white matter (793 versus 758 × 10 -6 mm 2 /s, P = .023), white matter tracts (797 versus 739 × 10 -6 mm 2 /s, P < .001), and deep gray matter (754 versus 713 × 10 -6 mm 2 /s, P = .016). ADC values trended higher in patients with Hunt and Hess 4-5 versus those with Hunt and Hess 1-3. Early cytotoxic edema was observed in 13 (39%) patients with SAH and was more prevalent in those with severe early brain injury (87.5% of patients with Hunt and Hess 4-5 versus 24.0% of those with Hunt and Hess 1-3, P = .001)., Conclusions: Age-adjusted ADC values were globally increased in patients with SAH compared with controls, even in normal-appearing brain regions, suggesting diffuse vasogenic edema. Cytotoxic edema was also present in patients with SAH and correlated with more severe early brain injury., (© 2017 by American Journal of Neuroradiology.)

Published
2017
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37. Neurologic complications of acute environmental injuries.

Author

da Silva IR and Frontera JA

Subjects
Humans, Hypothermia complications, Environmental Illness complications, Environmental Pollution adverse effects, Nervous System Diseases etiology
Abstract

Environmental injuries can result in serious neurologic morbidity. This chapter reviews neurologic complications of thermal burns, smoke inhalation, lightning strikes, electric injury, near drowning, decompression illness, as well as heat stroke and accidental hypothermia. Knowing the pathophysiology and clinical presentation of such injuries is essential to proper management of primary and secondary medical complications. This chapter highlights the most frequently encountered neurologic injuries secondary to common environmental hazards, divided into the topics: injuries related to fire, electricity, water, and the extremes of temperature., (© 2017 Elsevier B.V. All rights reserved.)

Published
2017
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38. Degree of Collaterals and Not Time Is the Determining Factor of Core Infarct Volume within 6 Hours of Stroke Onset.

Author

Cheng-Ching E, Frontera JA, Man S, Aoki J, Tateishi Y, Hui FK, Wisco D, Ruggieri P, Hussain MS, and Uchino K

Subjects
Area Under Curve, Female, Humans, Magnetic Resonance Imaging methods, Male, Middle Aged, Multivariate Analysis, ROC Curve, Stroke diagnostic imaging, Time Factors, Tomography, X-Ray Computed methods, Collateral Circulation, Stroke pathology
Abstract

Background and Purpose: Growth of the core infarct during the first hours of ischemia onset is not well-understood. We hypothesized that factors other than time from onset of ischemia contribute to core infarct volume as measured by MR imaging., Materials and Methods: Prospectively collected clinical and imaging data of consecutive patients with stroke presenting between March 2008 and April 2013 with anterior circulation large-vessel occlusion and MR imaging performed within 6 hours from the time of onset were reviewed. The association of time from onset, clinical, and radiographic features with DWI volume was assessed by using χ(2) and Mann-Whitney U tests., Results: Of 91 patients, 21 (23%) underwent MR imaging within 0-3 hours from onset, and 70 (76%), within 3-6 hours. Median MR imaging infarct volume was similar in both timeframes, (24.7 versus 29.4 mL, P = .906), and there was no difference in the proportion of patients with large infarct volumes (≥70 mL, 23.8% versus 22.8%, P = .928). Using receiver operating characteristic analysis, we detected no association between the time from onset and MR imaging infarct volume (area under the curve = 0.509). In multivariate analysis, CTA collaterals (>50% of the territory) (adjusted OR, 0.192; 95% CI, 0.04-0.9; P = .046), CTA ASPECTS (adjusted OR, 0.464; 95% CI, 0.3-0.8; P = .003), and a history of hyperlipidemia (adjusted OR, 11.0; 95% CI, 1.4-88.0; P = .023) (but not time from stroke onset to imaging) were independent predictors of MR imaging infarct volume., Conclusions: Collateral status but not time from stroke onset to imaging was a predictor of the size of core infarct in patients with anterior circulation large-vessel occlusion presenting within 6 hours from onset., (© 2015 by American Journal of Neuroradiology.)

Published
2015
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