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Martín-Palomeque G, Cabañes-Martínez L, López JR, Mateo Montero RC, Reyes A, Gandarias C, Regidor I. Usefulness of the H-Reflex for Intraoperative Monitoring of Thoracoabdominal Aneurysms. J Clin Neurophysiol 2024; 41:542-548. [PMID: 37255237 DOI: 10.1097/wnp.0000000000001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
PURPOSE Intraoperative neurophysiologic monitoring in thoracoabdominal aneurysms (TAAA) is essential to avoid intraoperative spinal cord injury). Motor and somatosensory evoked potentials may be considered intraoperative tools for detecting spinal cord injury. H-reflex is a well-known neurophysiologic technique to evaluate L5-S1 root. Current evidence supports the observation that H-reflex changes may occur with spinal cord damage as high as the cervical level. This study aimed to evaluate the usefulness of the H-reflex in these surgeries. METHODS The use of intraoperative H-reflex in TAAA monitoring was evaluated in 12 patients undergoing open or endovascular repair of TAAA for a period of four years (2016-2020) using somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TcMEPs) and bilateral H-reflex. RESULTS Six neurophysiologic alarms were recorded in five of the 12 patients. Summarizing the neurophysiologic changes of our series, we considered a peripheral change when we detected a unilateral loss of SSEPs, TcMEPs, and H-reflex. Instead, we assumed a central change when we detected a unilateral or bilateral loss of TcMEPs and H-reflex with normal SSEPs, which we considered a sign of spinal cord ischemia. Interestingly H-reflex always changed significantly in combination with TcMEPs in the same fashion. CONCLUSIONS According to our series, H-reflex can detect intraoperative changes with the same sensitivity as TcMEPs in TAAA surgeries. With the support of other techniques, it can be useful to localize the origin of the lesion (peripheral or central spinal cord), to help in surgical decision-making to avoid postoperative neurologic damage. Based on our results, we recommend the systematic use of H-reflex in TAAA surgeries.
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Affiliation(s)
| | | | - Jaime R López
- Departments of Neurology and Neurological Sciences and Neurosurgery, Stanford University School of Medicine, Stanford, California, U.S.A.; and
| | | | - Andrés Reyes
- Department of Vascular and Endovascular Surgery, Hospital Ramón y Cajal, Madrid, Spain
| | - Claudio Gandarias
- Department of Vascular and Endovascular Surgery, Hospital Ramón y Cajal, Madrid, Spain
| | - Ignacio Regidor
- Department of Clinical Neurophysiology, Hospital Ramón y Cajal, Madrid, Spain
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Yuno T, Nakade Y, Iino K, Taniguchi T, Oe H. Motor-Evoked Potential Monitoring With Multi-train Electrical Stimulation During Thoracoabdominal Aortic Aneurysm Surgery: A Case Report. Cureus 2024; 16:e53872. [PMID: 38465173 PMCID: PMC10924977 DOI: 10.7759/cureus.53872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/12/2024] Open
Abstract
Intraoperative motor-evoked potentials (MEPs) are measured for assessing motor function during surgery. MEP monitoring is often performed in thoracoabdominal aortic aneurysm (TAAA) surgery, but false positives are common and amplification methods are needed to obtain waveforms under severe conditions to assess proper spinal cord function. One method of amplitude amplification in transcranial-stimulated MEP monitoring is multitrain stimulation. There are few reports on multitrain-stimulated MEP monitoring for this surgery. A 57-year-old woman underwent open repair of the thoracoabdominal aorta due to a dissecting aortic aneurysm. After opening the chest, the aneurysm was incised proximally, and anastomosis with an artificial vessel was initiated. The lumbar artery leading to the Adam-Kiewicz artery was reconstructed at a body temperature of 25 °C. However, the single-train stimulation did not produce MEPs. When the measurement was switched to multitrain stimulation, MEPs were elicited in the lower extremity muscle groups and the waveforms were maintained until the end of the measurement. This case illustrates that MEP monitoring using multitrain stimulation during descending thoracic aortic aneurysm surgery can effectively elicit MEPs under challenging conditions, in which conventional single-train stimulation may be insufficient.
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Affiliation(s)
- Takeo Yuno
- Clinical Laboratory, Kanazawa University Hospital, Kanazawa, JPN
| | - Yusuke Nakade
- Clinical Laboratory, Kanazawa University Hospital, Kanazawa, JPN
| | - Kenji Iino
- Thoracic, Cardiovascular, and General Surgery, Kanazawa University, Kanazawa, JPN
| | - Takumi Taniguchi
- Emergency and Critical Care Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, JPN
| | - Hiroyasu Oe
- Clinical Laboratory, Kanazawa University Hospital, Kanazawa, JPN
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Holdefer RN, Seubert CN, Skinner SA, Humbert AT, Edwards ME, MacDonald DB. Analyzing the value of IONM as a complex intervention: The gap between published evidence and clinical practice. Clin Neurophysiol 2023; 151:59-73. [PMID: 37163826 DOI: 10.1016/j.clinph.2023.03.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 02/25/2023] [Accepted: 03/20/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Intraoperative neurophysiological monitoring (IONM) was investigated as a complex intervention (CI) as defined by the United Kingdom Medical Research Council (MRC) in published studies to identify challenges and solutions in estimating IONM's effects on postoperative outcomes. METHODS A scoping review to April 2022 of the influence of setting on what was implemented as IONM and how it influenced postoperative outcomes was performed for studies that compared IONM to no IONM cohorts. IONM complexity was assessed with the iCAT_SR tool. Causal graphs were used to represent this complexity. RESULTS IONM implementation depended on the surgical procedure, institution and/or surgeon. "How" IONM influenced neurologic outcomes was attributed to surgeon or institutional experience with the surgical procedure, surgeon or institutional experience with IONM, co-interventions in addition to IONM, models of IONM service delivery and individual characteristics of the IONM provider. Indirect effects of IONM mediated by extent of tumor resection, surgical approach, changes in operative procedure, shorter operative time, and duration of aneurysm clipping were also described. There were no quantitative estimates of the relative contribution of these indirect effects to total IONM effects on outcomes. CONCLUSIONS IONM is a complex intervention whose evaluation is more challenging than that of a simple intervention. Its implementation and largely indirect effects depend on specific settings that are usefully represented in causal graphs. SIGNIFICANCE IONM evaluation as a complex intervention aided by causal graphs and multivariable analysis could provide a valuable framework for future study design and assessments of IONM effectiveness in different settings.
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Affiliation(s)
- Robert N Holdefer
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.
| | - Christoph N Seubert
- Department of Anesthesiology, Division of Neuroanesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Stanley A Skinner
- Intraoperative Monitoring, Department of Neurophysiology, Abbott Northwestern Hospital, 800 E 28th Street, Minneapolis, MN 55407, USA
| | - Andrew T Humbert
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Mary E Edwards
- University of Florida Health Science Center Libraries, University of Florida, Gainesville, FL, USA
| | - David B MacDonald
- Arkana Forum Medical Education Center, Im Hausgrün 29, 79312, Emmendingen, Germany
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Patel PB, Patel VI. Single-staged hybrid repair of extent II thoracoabdominal aortic aneurysm with infrarenal abdominal aortic occlusion. J Vasc Surg Cases Innov Tech 2022; 8:218-221. [PMID: 35493342 PMCID: PMC9048036 DOI: 10.1016/j.jvscit.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 02/05/2022] [Indexed: 11/26/2022] Open
Abstract
Thoracoabdominal aortic aneurysm repair has been associated with a high risk of postoperative mortality, spinal cord ischemia, and renal failure. Endovascular repair combined with open repair in a two-staged hybrid approach has had a lower incidence of postoperative morbidity and mortality compared with open repair. In the present report, we have described single-stage hybrid repair of a complex chronic type B aortic dissection with a Crawford extent II thoracoabdominal aortic aneurysm in a patient with extensive prior aortic reconstruction.
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Simon MV, Dong CC, Jacobs MJ, Mess WH. Neuromonitoring during descending aorta procedures. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:407-431. [PMID: 35772899 DOI: 10.1016/b978-0-12-819826-1.00010-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Thoraco-abdominal aneurysm (TAA) repair carries a significant risk of spinal cord infarction. The latter results from irreversible changes in the spinal cord arterial network, e.g., sacrifice of the segmental arteries. Intra-operative neurophysiology with somatosensory and especially motor evoked potential (SEP and MEP respectively) monitoring, has emerged as an effective tool to assess the efficiency of the collateral blood flow, detect reversible spinal cord ischemia and guide the peri-operative multidisciplinary management to prevent postoperative paraplegia. The main roles of such monitoring include diagnosis of spinal cord vs peripheral limb ischemia, titration of mean arterial pressure during aortic clamping, the guidance of selective re-implantation of critical segmental arteries, and management of hemodynamics in the immediate postoperative period. In addition, manipulation of the aortic arch and proximal descending aorta, adds the risk of cerebral infarction from both low flow state and/or thromboembolic events. As such, EEG monitoring may be a useful add-on for either assessment of the efficiency of cerebral cooling as a neuroprotective method and/or for detection and treatment of reversible cerebral ischemia. This chapter presents the multimodality approach to open TAA monitoring as a versatile tool for the prevention of devastating postoperative neurologic deficits.
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Affiliation(s)
- Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.
| | - Charles C Dong
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Michael J Jacobs
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Werner H Mess
- Department of Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
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Nuwer MR, MacDonald DB, Gertsch J. Monitoring scoliosis and other spinal deformity surgeries. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:179-204. [PMID: 35772886 DOI: 10.1016/b978-0-12-819826-1.00014-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Surgery to correct a spinal deformity incurs a risk of injury to the spinal cord and roots. Injuries include postoperative paraplegia. Surgery for cervical myelopathy also incurs risk for postoperative motor deficits, as well as nerve injury most commonly at the C5 root. Risks can be mitigated by monitoring the nervous system during surgery. Ideally, monitoring detects an impending injury in time to intervene and correct the impairment before it becomes permanent. Monitoring includes several modalities of testing. Somatosensory evoked potentials measure axonal conduction in the spinal cord posterior columns. This can be checked almost continuously during surgery. Motor evoked potentials measure conduction along the lateral corticospinal tracts. Because motor pathway stimulation often produces a patient movement on the table, these often are tested periodically rather than continuously. Electromyography observes for spontaneous discharges accompanying injuries, and is useful to assess misplacement of pedicle screws. Literature demonstrates the usefulness of these techniques, their association with reducing motor adverse outcomes, and the relative value of the techniques. Neurophysiologic monitoring for scoliosis, kyphosis, and cervical myelopathy surgery are addressed, along with background information about those conditions.
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Affiliation(s)
- Marc R Nuwer
- Departments of Neurology and Clinical Neurophysiology, David Geffen School of Medicine, University of California Los Angeles, and Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States.
| | | | - Jeffrey Gertsch
- Department of Neurology, UC San Diego Health, San Diego, CA, United States
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Santamaria AJ, Benavides FD, Saraiva PM, Anderson KD, Khan A, Levi AD, Dietrich WD, Guest JD. Neurophysiological Changes in the First Year After Cell Transplantation in Sub-acute Complete Paraplegia. Front Neurol 2021; 11:514181. [PMID: 33536992 PMCID: PMC7848788 DOI: 10.3389/fneur.2020.514181] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/05/2020] [Indexed: 12/15/2022] Open
Abstract
Neurophysiological testing can provide quantitative information about motor, sensory, and autonomic system connectivity following spinal cord injury (SCI). The clinical examination may be insufficiently sensitive and specific to reveal evolving changes in neural circuits after severe injury. Neurophysiologic data may provide otherwise imperceptible circuit information that has rarely been acquired in biologics clinical trials in SCI. We reported a Phase 1 study of autologous purified Schwann cell suspension transplantation into the injury epicenter of participants with complete subacute thoracic SCI, observing no clinical improvements. Here, we report longitudinal electrophysiological assessments conducted during the trial. Six participants underwent neurophysiology screening pre-transplantation with three post-transplantation neurophysiological assessments, focused on the thoracoabdominal region and lower limbs, including MEPs, SSEPs, voluntarily triggered EMG, and changes in GSR. We found several notable signals not detectable by clinical exam. In all six participants, thoracoabdominal motor connectivity was detected below the clinically assigned neurological level defined by sensory preservation. Additionally, small voluntary activations of leg and foot muscles or positive lower extremity MEPs were detected in all participants. Voluntary EMG was most sensitive to detect leg motor function. The recorded MEP amplitudes and latencies indicated a more caudal thoracic level above which amplitude recovery over time was observed. In contrast, further below, amplitudes showed less improvement, and latencies were increased. Intercostal spasms observed with EMG may also indicate this thoracic “motor level.” Galvanic skin testing revealed autonomic dysfunction in the hands above the injury levels. As an open-label study, we can establish no clear link between these observations and cell transplantation. This neurophysiological characterization may be of value to detect therapeutic effects in future controlled studies.
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Affiliation(s)
- Andrea J Santamaria
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Francisco D Benavides
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Pedro M Saraiva
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Kimberly D Anderson
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Aisha Khan
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,Miller School of Medicine, The Interdisciplinary Stem Cell Institute, The University of Miami, Miami, FL, United States
| | - Allan D Levi
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - W Dalton Dietrich
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - James D Guest
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
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Abstract
BACKGROUND Spinal cord ischemia (SCI) is a rare but devastating condition that can occur in the perioperative period resulting in paraplegia. Although diabetes mellitus is a risk factor for SCI in other types of major surgery, SCI is not widely recognized in transplantation. The aim of this study was to quantify the risk of SCI in pancreatic transplantation. METHODS All UK pancreas transplant units were surveyed between 2017 and 2018. The risk of SCI in pancreas transplantation was estimated using the number of radiologically confirmed cases relative to the number of pancreatic transplants from UK registry data during the same time period. RESULTS There have been 6 cases of SCI during pancreas transplantation since 2002. No aortic clamping occurred in any recipient. During or after surgery, all patients experienced episodes of hypotension (systolic blood pressure ≤ 90 mm Hg) before the onset of neurological symptoms. Epoprostenol, epidural anesthesia, and postoperative hemodialysis may have contributed to systemic hypotension. The mainstay of early treatment for SCI for all cases was blood pressure control. CONCLUSIONS Based on these findings, there is approximately a 1:440 risk of SCI in pancreas transplantation. Hypotension appears to be a prominent risk factor. Strategies for mitigating the risk of SCI are discussed, drawing on evidence from thoraco-abdominal aortic aneurysm surgery. The risk of long-term neurological deficit should be discussed with prospective pancreas recipients given the potential impact on posttransplant quality of life.
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Yoshitani K, Masui K, Kawaguchi M, Kawamata M, Kakinohana M, Kato S, Hasuwa K, Yamakage M, Yoshikawa Y, Nishiwaki K, Aoyama T, Inagaki Y, Yamasaki K, Matsumoto M, Ishida K, Yamashita A, Seo K, Kakumoto S, Hayashi H, Tanaka Y, Tanaka S, Ishida T, Uchino H, Kakinuma T, Yamada Y, Mori Y, Izumi S, Nishimura K, Nakai M, Ohnishi Y. Clinical Utility of Intraoperative Motor-Evoked Potential Monitoring to Prevent Postoperative Spinal Cord Injury in Thoracic and Thoracoabdominal Aneurysm Repair: An Audit of the Japanese Association of Spinal Cord Protection in Aortic Surgery Database. Anesth Analg 2018; 126:763-768. [PMID: 29283918 DOI: 10.1213/ane.0000000000002749] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Spinal cord ischemic injury is the most devastating sequela of descending and thoracoabdominal aortic surgery. Motor-evoked potentials (MEPs) have been used to intraoperatively assess motor tract function, but it remains unclear whether MEP monitoring can decrease the incidence of postoperative motor deficits. Therefore, we reviewed multicenter medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open surgery and endovascular repair) to assess the association of MEP monitoring with postoperative motor deficits. METHODS Patients included in the study underwent descending or thoracoabdominal aortic repair at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery between 2000 and 2013. Using multivariable mixed-effects logistic regression analysis, we investigated whether intraoperative MEP monitoring was associated with postoperative motor deficits at discharge after open and endovascular aortic repair. RESULTS We reviewed data from 1214 patients (open surgery, 601 [49.5%]; endovascular repair, 613 [50.5%]). MEP monitoring was performed in 631 patients and not performed in the remaining 583 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. Multivariable logistic regression analysis revealed that postoperative motor deficits at discharge did not have a significant association with MEP monitoring (adjusted odds ratio [OR], 1.13; 95% confidence interval [CI], 0.69-1.88; P = .624), but with other factors: history of neural deficits (adjusted OR, 6.08; 95% CI, 3.10-11.91; P < .001), spinal drainage (adjusted OR, 2.14; 95% CI, 1.32-3.47; P = .002), and endovascular procedure (adjusted OR, 0.45; 95% CI, 0.27-0.76; P = .003). The sensitivity and specificity of MEP <25% of control value for motor deficits at discharge were 37.8% (95% CI, 26.5%-49.5%) and 95.5% (95% CI, 94.7%-96.4%), respectively. CONCLUSIONS MEP monitoring was not significantly associated with motor deficits at discharge.
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Affiliation(s)
- Kenji Yoshitani
- From the Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenichi Masui
- Department of Anesthesiology, National Defense Medical College, Tokorozawa, Japan.,Department of Anesthesiology, Showa University School of Medicine, Tokyo, Japan
| | | | - Mikito Kawamata
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Manabu Kakinohana
- Department of Anesthesiology, University of Ryukyu, Faculty of Medicine, Nishihara, Japan
| | - Shinya Kato
- From the Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kyoko Hasuwa
- From the Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Yusuke Yoshikawa
- Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Chikusa-ku, Nagoya
| | - Tadashi Aoyama
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Chikusa-ku, Nagoya
| | - Yoshimi Inagaki
- Department of Anesthesiology and Critical Care and Medicine, Tottori University, Faculty of Medicine, Tottori, Japan
| | - Kazumasa Yamasaki
- Department of Anesthesiology and Critical Care and Medicine, Tottori University, Faculty of Medicine, Tottori, Japan
| | - Mishiya Matsumoto
- Department of Anesthesiology, Yamaguchi University, Graduate School of Medicine, Ube, Japan
| | - Kazuyoshi Ishida
- Department of Anesthesiology, Yamaguchi University, Graduate School of Medicine, Ube, Japan
| | - Atsuo Yamashita
- Department of Anesthesiology, Yamaguchi University, Graduate School of Medicine, Ube, Japan
| | - Katsuhiro Seo
- Department of Anesthesiology and Intensive Care Medicine, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinichi Kakumoto
- Department of Anesthesiology and Intensive Care Medicine, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Hironobu Hayashi
- Department of Anesthesiology, Nara Medical University, Kashihara, Japan
| | - Yuu Tanaka
- Department of Anesthesiology, Nara Medical University, Kashihara, Japan
| | - Satoshi Tanaka
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takashi Ishida
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroyuki Uchino
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Takayasu Kakinuma
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Yoshitsugu Yamada
- Department of Anesthesiology, Faculty of Vital Care Medicine, The Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshiteru Mori
- Department of Anesthesiology, Faculty of Vital Care Medicine, The Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunsuke Izumi
- Department of Anesthesiology, University of Ryukyu, Faculty of Medicine, Nishihara, Japan
| | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshihiko Ohnishi
- From the Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Japan
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Oxidative Stress, Selenium Redox Systems Including GPX/TXNRD Families. MOLECULAR AND INTEGRATIVE TOXICOLOGY 2018. [DOI: 10.1007/978-3-319-95390-8_6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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