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69. Outcomes after coronal alignment correction in patients with trunk shift toward the curve convexity [Meeting Abstract]

Dinizo, M; Srisanguan, K; Errico, T J; Raman, T
BACKGROUND CONTEXT: Patients with coronal malalignment with trunk shift toward the convexity of the main coronal curve, and oblique takeoff at the lumbosacral junction, present a unique problem for deformity correction. PURPOSE: To evaluate fractional curve and coronal malalignment correction, and rate of complications and unplanned revision in Bao Type C patients, compared to Bao Type A and B patients. STUDY DESIGN/SETTING: Retrospective review of prospectively collected singlecenter database. PATIENT SAMPLE: This study included 1039 ASD patients (age: 46 +/- 23 y; mFI:.4 +/-.7; levels fused: 10.0 +/- 4.2). OUTCOME MEASURES: Outcomes evaluated were coronal alignment and fractional curve correction, and rates of revision surgery at two-year follow-up.
METHOD(S): A total of 1039 adult spinal deformity patients (age: 46 +/- 23 y; mFI:.4 +/-.7; levels fused: 10.0 +/- 4.2), with minimum five levels fused for thoracolumbar scoliosis were divided into three groups, as proposed by Bao et al: type A: CSVL 3cm and C7 plumb shifted to scoliosis' concavity (n=126); type C: CSVL > 3cm and C7 plumb shifted to scoliosis' convexity (n=30). Outcomes evaluated were coronal alignment and fractional curve correction, and rates of revision surgery at two-year follow-up.
RESULT(S): Type C patients more often had fractional curves, and the preoperative magnitude was significantly greater (15.7degree Type C, 12.9degree Type B, 9.6degree Type A, p <0.0001). Of the Type C patients, 50% had pedicle subtraction osteotomy performed, compared with 13.4% Type B, and 13.4% Type A (p <0.0001). Postoperatively, Type C patients continued to have persistently greater fractional curves (7.4degree Type C, 6.7degree Type B, 5.6degree Type A, p=0.026), and worse coronal malalignment (37.8 mm Type C, 34.1 mm Type B, 17.0 mm type A, p<0.0001), though equivalent results with regards to improvement in sagittal alignment, lumbar lordosis, pelvic tilt, and Cobb angle of the major curve. There rate of neurologic complications was higher in the Type C patients, specifically related to TLIF or PSO procedure performed. ALIF procedure in the Type C patients did not confer significant improvement in fractional curve correction, coronal or sagittal alignment correction, or greater lumbar lordosis, compared with TLIF procedure in these patients. There was no difference in the rate of 90-day unplanned readmission or reoperation between the groups. There was no difference in rates of rod fracture or pseudarthrosis at the interbody or PSO site in Type C patients, compared with Type A and B patients. There was no difference in rates or rod fracture, pseudarthrosis, adjacent segment disease, proximal junctional kyphosis, or reoperation for recurrent or persistent malalignment between the two groups at two-year follow-up.
CONCLUSION(S): At two-year follow-up, Type C coronal malalignment patients continue to have worse coronal deformity and fractional curve magnitude compared with Type A and B patients, with no difference, however, in long-term rod fracture, pseudarthrosis or revision surgery rates. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
Copyright
EMBASE:2019804838
ISSN: 1878-1632
CID: 5510412

P148. Treatment of the fractional curve with interbody fusion L4-S1 versus posterior fusion alone: impact on surgical outcomes and complications [Meeting Abstract]

Srisanguan, K; Dinizo, M; Errico, T J; Raman, T
BACKGROUND CONTEXT: The fractional curve is the curve below the major curve of a lumbar or thoracolumbar scoliosis, and while it is often the primary driver of the adult spinal deformity patient's decision to proceed with surgery, a treatment strategy to identify and address the fractional curve is not widely examined. There is a paucity of data evaluating the ideal strategy to correct the lumbosacral fractional curve in ASD surgery. PURPOSE: We sought to evaluate the impact of interbody fusion at L4-L5 and/or L5-S1 compared with posterior fusion alone on fractional curve correction, and rate of instrumentation related complications at the lumbosacral junction. STUDY DESIGN/SETTING: Retrospective review of prospectively collected single center database. PATIENT SAMPLE: A total of 592 ASD patients (Age: 48 +/- 23 y; mFI:.4 +/-.7; Levels fused: 10.3 +/- 4.1). OUTCOME MEASURES: Outcomes evaluated were fractional curve correction, overall deformity correction and rates of revision surgery for pseudarthrosis or rod fracture at the lumbosacral junction.
METHOD(S): A total of 592 ASD patients (Age: 48 +/- 23 y; mFI:.4 +/-.7; Levels fused: 10.3 +/- 4.1), lumbosacral fractional curve > 10degree, mean followup 39.5 months, were divided into 2 groups: PSF alone (PSF, n=382) and interbody fusion (IBF, n=210; ALIF: 31, TLIF: 179). Outcomes evaluated were fractional curve correction, overall deformity correction and rates of revision surgery for pseudarthrosis or rod fracture at the lumbosacral junction.
RESULT(S): A significantly greater number of patients in the IB cohort had underlying osteoporosis (63% versus 33%, p < 0.001); otherwise, there were no significant difference in patient comorbidities. There was significantly greater EBL (2.3 L vs. 1.3 L, p < 0.0001), intraoperative pRBCs transfused (2.3 U vs. 1.3 U, p < 0.001), and longer operative time (7.1 vs. 6.3 hours, p < 0.0001) in the IBF group compared with PSF. Both groups had similar magnitude of fractional curve correction (7.0 +/-7.1degree in IB vs. 6.3 +/- 6.9degree in PSF, p=0.26) and final coronal alignment (23.5 mm vs. 19.8 mm, p=0.08). Patients in the IBF group had a higher magnitude of SVA change (-30.6 mm vs -19.5 mm, p < 0.05) and increase in lumbar lordosis (11.5degree vs 5.6degree, p < 0.001). There was no difference in the rate of revision surgery at minimum 2-year followup for rod fracture, pseudarthrosis, or any instrumentation related complication. Sub-analysis demonstrated that there were no significant differences in magnitude of fractional curve correction, or improvement in lumbar lordosis, coronal, or sagittal alignment in the ALIF group compared to the TLIF group. There was no significant impact of number of levels at which a lumbar interbody fusion was performed on the degree of fractional curve correction.
CONCLUSION(S): At minimum 2-year followup, patients had comparable fractional curve and coronal alignment correction when treated with interbody fusion at L4-S1 versus posterior fusion alone. There was no difference in rod fracture and pseudarthrosis rates at 2-year followup. These data suggest that utilization of interbody technique at the lumbosacral junction is not clearly superior to posterior fusion alone for treatment of the fractional curve. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
Copyright
EMBASE:2019804090
ISSN: 1878-1632
CID: 5510682

159. Impact of smoking status on early and late outcomes after adult spinal deformity surgery [Meeting Abstract]

Srisanguan, K; Dinizo, M; Errico, T J; Raman, T
BACKGROUND CONTEXT: It has been shown that smoking is associated with delayed fusion and pseudarthrosis after spine surgery. The impact of smoking on both short- and long-term outcomes in patients undergoing spine surgery has been described. There are limited data on the impact of smoking status on outcomes after adult spinal deformity (ASD) surgery. We sought to analyze a large cohort of in a single center, to add more to our understanding of the effect of smoking both on mortality and postoperative complications. PURPOSE: To evaluate the effect of smoking on 90-day complications after ASD surgery as well as pseudarthrosis and unplanned revision at long term follow up. STUDY DESIGN/SETTING: Retrospective review of prospectively collected database. PATIENT SAMPLE: A total of 1,013 ASD patients (Age: 46 +/-23 years; mFI: 0.44 +/- 0.70; levels fused: 10.1 +/- 4.2). OUTCOME MEASURES: Outcome measures studied included perioperative complications, and long-term revision surgery rates.
METHOD(S): A total of 1,013 ASD patients (Age: 46 +/-23 ye ars; mFI: 0.44 +/- 0.70; levels fused: 10.1 +/- 4.2) were stratified based on smoking status into three groups. Current smokers group (n = 72) included all patients who were active smokers and those who quit smoking within 4 weeks of surgery. Former smokers group (n = 265) included all patients who quit smoking more than 4 weeks before surgery. Nonsmokers (n = 676) included all patients who had never smoked in their lives before surgery. Outcome measures studied included perioperative complications and long-term revision surgery rates.
RESULT(S): With regards to early complications, the readmission rate at 90 days was significantly higher in the current (12.7%) and former smokers (12.0%), compared with nonsmokers (6.1%) (p=0.007). There was a significantly higher rate of postoperative epidural hematoma in smokers (5%), compared to former and nonsmokers (0%) (p<0.001). There was a higher rate of postoperative pneumonia in smokers (4.5%) compared to former smokers (1.4%) and nonsmokers (0.07%) (p=0.038). There was no significant difference in length of stay between the groups. At minimum one-year follow up, there was a significantly higher rate of pseudarthrosis (smokers: 15.6%, former: 6.7%, non: 4.5%, p=0.041) with no significant difference in rate of revision surgery for pseudarthrosis. Smokers had a significantly higher rate of neurologic complications (29% vs 18.5%, p=0.001) compared to nonsmokers. Smokers who did not experience any resolution of the neurologic injury had greater pack year history (28.5 +/-22) versus smokers who experienced complete resolution (21.2 +/- 39.3) (p=0.02).
CONCLUSION(S): Smoking is associated with higher 90-day readmission rate, and higher rates of epidural hematoma, neurologic complication and postoperative pneumonia after ASD surgery. At one year, smokers have a higher rate of pseudarthrosis, and those with greater pack year history were less likely to experience resolution of the neurologic injury sustained at the index surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
Copyright
EMBASE:2019803813
ISSN: 1878-1632
CID: 5511152

Case Start Timing of Adult Spinal Deformity Surgeries: Does the Wait Matter?

Dinizo, Michael; Patel, Karan; Dolgalev, Igor; Passias, Peter G; Errico, Thomas J; Raman, Tina
BACKGROUND:Adult spinal deformity (ASD) surgery can entail complex reconstructive procedures. It is unclear whether there is any effect of case start time on outcomes. We sought to evaluate the effects of case start time and day of the week on 90-day complication, readmission, and revision rates after ASD surgery. METHODS:This is a retrospective study of 1040 ASD patients from a single institution. We collected start times and day of the week for cases from 2011 to 2018. Early start was designated as any case starting either before or at 7:30 am or between 7:30 and 11 am; late start was designated as any case starting at 11 am or later. Outcome measures include 90-day complication, revision, and readmission rates. RESULTS:= 0.046). CONCLUSIONS:A late OR start time was predictive of increased risk for neurologic complication, 90-day readmission, and unplanned reoperation. The well-established protocols for first start OR times for elective ASD surgery may decrease outcome risk and reduce variability in complication rates. CLINICAL RELEVANCE/CONCLUSIONS:Understanding the impact of start time on outcomes and complications after ASD surgery is helpful for surgeons in preoperative planning and for institutions and hospitals' allocation of operating room staff and resources. LEVEL OF EVIDENCE/METHODS:3.
PMID: 35177531
ISSN: 2211-4599
CID: 5175742

Not Frail and Elderly: How Invasive Can We Go In This Different Type of Adult Spinal Deformity Patient?

Passias, Peter G; Pierce, Katherine E; Passfall, Lara; Adenwalla, Ammar; Naessig, Sara; Ahmad, Waleed; Krol, Oscar; Kummer, Nicholas A; O'Malley, Nicholas; Maglaras, Constance; O'Connell, Brooke; Vira, Shaleen; Schwab, Frank J; Errico, Thomas J; Diebo, Bassel G; Janjua, Burhan; Raman, Tina; Buckland, Aaron J; Lafage, Renaud; Protopsaltis, Themistocles; Lafage, Virginie
STUDY DESIGN/METHODS:Retrospective review of a single-center spine database. OBJECTIVE:Investigate the intersections of chronological age and physiological age via frailty to determine the influence of surgical invasiveness on patient outcomes. SUMMARY OF BACKGROUND DATA/BACKGROUND:Frailty is a well-established factor in preoperative risk stratification and prediction of postoperative outcomes. The surgical profile of operative adult spinal deformity (ASD) patients who present as elderly and not frail has yet to be investigated. Our aim was to examine the surgical profile and outcomes of ASD patients who were not frail and elderly. METHODS:Included: ASD patients≥18 years old, ≥4 levels fused, with baseline(BL) and follow up data. Patients were categorized by ASD frailty index: Not Frail[NF], Frail[F], Severely Frail [SF]. An elderly patient was defined as ≥70 years. Patients were grouped into NF/elderly and F/elderly. SRS-Schwab modifiers were assessed at baseline and 1-year(0, +, ++). Logistic regression analysis assessed the relationship between increasing invasiveness, no reoperations, or major complications, and improvement in SRS-Schwab modifiers[Good Outcome]. Decision tree analysis assessed thresholds for an invasiveness risk/benefit cutoff point. RESULTS:598 ASD pts included(55.3yrs, 59.7%F, 28.3 kg/m2). 29.8% of patients were above age 70. At baseline, 51.3% of patients were NF, 37.5% F, and 11.2% SF. 66(11%) of patients were NF and elderly. 24.2% of NF-Elderly patients improved in SRS-Schwab by 1-year and had no reoperation or complication postoperatively. Binary regression analysis found a relationship between worsening SRS-Schwab, postop complication, and reoperation with invasiveness score(OR: 1.056[1.013-1.102], p = 0.011). Risk/benefit cut-off was 10(p = 0.004). Patients below this threshold were 7.9[2.2-28.4] times more likely to have a Good Outcome. 156 patients were elderly and F/SF with 16.7% having Good Outcome, with a risk/benefit cut-off point of <8 (4.4[2.2-9.0], p < 0.001). CONCLUSIONS:Frailty status impacted the balance of surgical invasiveness relative to operative risk in an inverse manner, while the opposite was seen amongst elderly patients with a frailty status less than their chronologic age. Surgeons should perhaps consider incorporation of frailty status over age status when determining realignment plans in patients of advanced age.Level of Evidence: ???
PMID: 34132235
ISSN: 1528-1159
CID: 4932612

Pseudarthrosis and Rod Fracture Rates After Transforaminal Lumbar Interbody Fusion at the Caudal Levels of Long Constructs for Adult Spinal Deformity Surgery

Dinizo, Michael; Srisanguan, Karnmanee; Dolgalev, Igor; Errico, Thomas J; Raman, Tina
BACKGROUND:Interbody fusion at the caudal levels of long constructs for adult spinal deformity (ASD) surgery is used to promote fusion and secure a solid foundation for maintenance of deformity correction. We sought to evaluate long-term pseudarthrosis, rod fracture, and revision rates for TLIF performed at the base of a long construct for ASD. METHODS:We reviewed 316 patients who underwent TLIF as a component of ASD surgery for medical comorbidities, surgical characteristics, and rate of unplanned reoperation for pseudarthrosis or instrumentation failure at the TLIF level. Fusion grading was assessed after revision surgery for pseudarthrosis at the TLIF level. RESULTS:Rate of pseudarthrosis at the TLIF level was 9.8% (31/316), and rate of rod fractures was 7.9% (25/316). The rate of revision surgery at the TLIF level was 8.9% (28/316), and surgery was performed at a mean of 20.4 ± 16 months from the index procedure. Current smoking status (odds ratio 3.34, P = 0.037) was predictive of pseudarthrosis at the TLIF site. At a mean follow-up of 43 ± 12 months after revision surgery, all patients had achieved bony union at the TLIF site. CONCLUSIONS:At 3-year follow-up, the rate of pseudarthrosis after TLIF performed at the base of a long fusion for ASD was 9.8%, and the rate of revision surgery to address pseudarthrosis and/or rod fracture was 8.9%. All patients were successfully treated with revision interbody fusion or posterior augmentation of the fusion mass, without need for further revision procedures at the TLIF level.
PMID: 34474159
ISSN: 1878-8769
CID: 5067002

Topical tranexemic acid reduces intra-operative blood loss and transfusion requirements in spinal deformity correction in patients with adolescent idiopathic scoliosis

George, Stephen; Ramchandran, Subaraman; Mihas, Alexander; George, Kevin; Mansour, Ali; Errico, Thomas
PURPOSE/OBJECTIVE:To evaluate the effectiveness of the use of topical tranexamic acid (tTXA) in spinal deformity correction in AIS patients METHODS: Sixty consecutive operative AIS patients were reviewed from a single institution and divided into two groups with similar demographics. Standardized peri-operative blood salvage techniques were utilized in all 60 patients. In the latter 30 patients, tTXA soaked sponges (1 g mixed in 500 ml Normal Saline) was utilised for wound packing during the entire surgical procedure compared to dry sponges as used in the former 30 patients. Both the groups were compared for the magnitude of deformity corrected, EBL per level fused, total EBL, blood transfused, drain output and peri-operative events. RESULTS:Sixty AIS patients (mean age 14.4 yrs, 43 females, mean BMI 21.5, mean levels 10.7) were included. Both groups achieved similar change in Coronal Cobb correction. The EBVL (Estimated blood volume loss) % lost in the topical TXA group was 38% less than the control group (11.2 vs. 18.3%, p = 0.006). Similarly, the EBL/level was significantly lower in the topical TXA group (41 ± 30 ml vs. 57 ± 26 ml, p = 0.03). Three of 30 patients in the control group required at least 1 unit of blood transfusion, whereas only 1 patient in the topical TXA group required transfusion (10 vs. 3.3%, p = 0.001). No differences were noted in post-operative drain output, change in hemoglobin levels, and peri-operative complication rates. CONCLUSION/CONCLUSIONS:When used as an adjunct to the conventional blood salvage techniques in spinal deformity correction procedures, the use of tTXA resulted in reduced operative blood loss, and blood transfusion requirements.
PMID: 33844193
ISSN: 2212-1358
CID: 4845742

Residual lumbar hyperlordosis is associated with worsened hip status 5 years after scoliosis correction in non-ambulant patients with cerebral palsy

Buckland, Aaron J; Woo, Dainn; Kerr Graham, H; Vasquez-Montes, Dennis; Cahill, Patrick; Errico, Thomas J; Sponseller, Paul D
BACKGROUND:Cerebral palsy (CP) is a static encephalopathy with progressive musculoskeletal pathology. Non-ambulant children (GMFCS IV and V) with CP have high rates of spastic hip disease and neuromuscular scoliosis. The effect of spinal fusion and spinal deformity on hip dislocation following total hip arthroplasty has been well studied, however in CP this remains largely unknown. This study aimed to identify factors associated with worsening postoperative hip status (WHS) following corrective spinal fusion in children with GMFCS IV and V CP. METHODS:Retrospective review of GMFSC IV and V CP patients in a prospective multicenter database undergoing spinal fusion, with 5 years follow-up. WHS was determined by permutations of baseline (BL), 1 year, 2 years, and 5 years hip status and defined by a change from an enlocated hip at BL that became subluxated, dislocated or resected post-op, or a subluxated hip that became dislocated or resected. Hip status was analyzed against patient demographics, hip position, surgical variables, and coronal and sagittal spinal alignment parameters. Cutoff values for parameters at which the relationship with hip status was significant was determined using receiver operating characteristic curves. Logistic regression determined odds ratios for predictors of WHS. RESULTS:Eighty four patients were included. 37 (44%) had WHS postoperatively. ROC analysis and logistic regression demonstrated that the only spinopelvic alignment parameter that significantly correlated with WHS was lumbar hyperlordosis (T12-L5) > 60° (p = 0.028), OR = 2.77 (CI 1.10-6.94). All patients showed an increase in pre-to-postop LL. Change in LL pre-to-postop was no different between groups (p = 0.318), however the WHS group was more lordotic at BL and postop (pre44°/post58° vs pre32°/post51° in the no change group). Age, sex, Risser, hip position, levels fused, coronal parameters, global sagittal alignment (SVA), thoracic kyphosis, and reoperation were not associated with WHS. CONCLUSION/CONCLUSIONS:Postoperative hyperlordosis(> 60°) is a risk factor for WHS at 5 years after spinal fusion in non-ambulant CP patients. WHS likely relates to anterior pelvic tilt and functional acetabular retroversion due to hyperlordosis, as well as loss of protective lumbopelvic motion causing anterior femoracetabular impingement. LEVEL OF EVIDENCE/METHODS:III.
PMID: 33523455
ISSN: 2212-1358
CID: 4775942

Characteristics and Trends of the Most Cited Spine Publications

Donnally, Chester J; Lugo-Pico, Julian G; Bondar, Kevin J; Chen, Clark J; McCormick, Johnathon R; Errico, Thomas J
STUDY DESIGN/METHODS:Bibliometric literature review. OBJECTIVE:The aim of this study was to recognize and analyze the most frequently cited manuscripts published in the journal Spine. SUMMARY OF BACKGROUND DATA/BACKGROUND:Although the journal Spine is considered a premiere location for distributing influential spine research, no previous study has evaluated which of their publications have had the most impact. Knowledge and appreciation of the most influential Spine publications can guide and inspire future research endeavors. METHODS:Using the Scopus database, the 100 most cited articles published in Spine were accessed. The frequency of citations, year of publication, country of origin, level-of-evidence (LOE), article type, and contributing authors/institutions were recorded. The 10 most cited articles (per year) from the past decade were also determined. RESULTS:"Guidelines For The Process Of Cross-Cultural Adaptation Of Self-Report Measures" by Beaton DE was the most cited article with 2960 citations. 2000 to 2009 (n = 46) was the most productive period. A LOE of III (n = 35) followed by II (n = 34) were the most common. Deyo RA (n = 8), Bombardier C (n = 6), and Waddell G (n = 6) produced the most articles. University of Washington (n = 8) and University of Toronto (n = 8) ranked first for institutional output. Clinical Outcome (n = 28) was the most recurring article topic. The United States (n = 51) ranked first for country of origin. CONCLUSION/CONCLUSIONS:Using citation analysis as an objective proxy for influence, certain publications can be distinguished from others due to their lasting impact and recognition from peers. Of the top cited Spine publications, many pertained to clinical outcomes (28%) and had a LOE of I, II, or III (60%). Although older publications have had longer time to accrue citations, those in the most recent decade comprise this list almost 2:1. Knowledge of these "classic" publications allows for a better overall understanding of the diagnosis, management, and future direction of spine health care.Level of Evidence: 3.
PMID: 33337672
ISSN: 1528-1159
CID: 4718272

Clinical photographs in the assessment of adult spinal deformity: a comparison to radiographic parameters

Ryan, Devon J; Stekas, Nicholas D; Ayres, Ethan W; Moawad, Mohamed A; Balouch, Eaman; Vasquez-Montes, Dennis; Fischer, Charla R; Buckland, Aaron J; Errico, Thomas J; Protopsaltis, Themistocles S
OBJECTIVE:The goal of this study was to reliably predict sagittal and coronal spinal alignment with clinical photographs by using markers placed at easily localized anatomical landmarks. METHODS:A consecutive series of patients with adult spinal deformity were enrolled from a single center. Full-length standing radiographs were obtained at the baseline visit. Clinical photographs were taken with reflective markers placed overlying C2, S1, the greater trochanter, and each posterior-superior iliac spine. Sagittal radiographic parameters were C2 pelvic angle (CPA), T1 pelvic angle (TPA), and pelvic tilt. Coronal radiographic parameters were pelvic obliquity and T1 coronal tilt. Linear regressions were performed to evaluate the relationship between radiographic parameters and their photographic "equivalents." The data were reanalyzed after stratifying the cohort into low-body mass index (BMI) (< 30) and high-BMI (≥ 30) groups. Interobserver and intraobserver reliability was assessed for clinical measures via intraclass correlation coefficients (ICCs). RESULTS:A total of 38 patients were enrolled (mean age 61 years, mean BMI 27.4 kg/m2, 63% female). All regression models were significant, but sagittal parameters were more closely correlated to photographic parameters than coronal measurements. TPA and CPA had the strongest associations with their photographic equivalents (both r2 = 0.59, p < 0.001). Radiographic and clinical parameters tended to be more strongly correlated in the low-BMI group. Clinical measures of TPA and CPA had high intraobserver reliability (all ICC > 0.99, p < 0.001) and interobserver reliability (both ICC > 0.99, p < 0.001). CONCLUSIONS:The photographic measures of spinal deformity developed in this study were highly correlated with their radiographic counterparts and had high inter- and intraobserver reliability. Clinical photography can not only reduce radiation exposure in patients with adult spinal deformity, but also be used to assess deformity when full-spine radiographs are unavailable.
PMID: 33990080
ISSN: 1547-5646
CID: 4867902