1
|
Meyer MA, van den Bosch T, Millenaar Z, Heng M, Leenen L, Hietbrink F, Houwert RM, Kromkamp M, Nelen SD. Psychiatric comorbidity and trauma: impact on inpatient outcomes and implications for future management. Eur J Trauma Emerg Surg 2024; 50:439-446. [PMID: 37697154 DOI: 10.1007/s00068-023-02359-w] [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: 04/27/2023] [Accepted: 08/21/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE This study aimed to quantify the impact of pre-existing psychiatric illness on inpatient outcomes after major trauma and to assess acuity of psychiatric presentation as a predictor of outcomes. METHODS A retrospective single-center cohort study identified adult trauma patients with an Injury Severity Score (ISS) ≥ 16 between January 2018 and December 2019. Bivariate analysis assessed patient characteristics, injury characteristics, and injury outcomes between patients with and without psychiatric comorbidity. A sub-group analysis explored further effects of psychiatric history and need for inpatient psychiatric consultation on outcomes. RESULTS Of 640 patients meeting inclusion criteria, 99 patients (15.4%) had at least one psychiatric comorbidity. Patients with psychiatric comorbidity sustained distinct mechanisms of injury and higher in-hospital morbidity (44% vs. 26%, OR 1.97, 95% CI 1.17-3.3, p = 0.01), including pulmonary morbidity (31% vs. 21%, p < 0.01), neurologic morbidity (18% vs 7%, p < 0.01), and deep wound infection (8% vs. 2%, p < 0.01) than the control cohort. Psychiatric patients also had significantly greater median intensive care unit (ICU), length of stay (LOS) (1 day vs. 0 days, p = 0.04), median inpatient ward LOS (10 days vs. 7 days, p = 0.02), and median overall hospital LOS (16 days vs. 11 days, p < 0.01). In sub-group analysis, patients with a history of psychiatric illness alone had comparable outcomes to the control group. CONCLUSIONS Psychiatric comorbidity negatively impacts inpatient morbidity and inpatient LOS. This effect is most pronounced among acute psychiatric episodes with or without a history of mental illness.
Collapse
Affiliation(s)
- Maximilian Arthur Meyer
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
- Department of Orthopedic Surgery, Massachusetts General Hospital, 55 Fruit Street, White Building 535, Boston, MA, 02114, USA.
| | - Tijmen van den Bosch
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Zita Millenaar
- Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marilyn Heng
- Department of Orthopedic Surgery, Massachusetts General Hospital, 55 Fruit Street, White Building 535, Boston, MA, 02114, USA
| | - Loek Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Marjan Kromkamp
- Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stijn Diederik Nelen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
2
|
Meyer MA, van den Bosch T, Haagsma JA, Heng M, Leenen LPH, Hietbrink F, Houwert RM, Kromkamp M, Nelen SD. Influence of psychiatric co-morbidity on health-related quality of life among major trauma patients. Eur J Trauma Emerg Surg 2022; 49:965-971. [PMID: 36152068 DOI: 10.1007/s00068-022-02114-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/17/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The purpose of this study was to compare 1-year post-discharge health-related quality of life (HRQL) between trauma patients with and without psychiatric co-comorbidity. METHODS A retrospective single-center cohort study identified all severely injured adult trauma patients admitted to a Level 1 trauma center between 2018 and 2019. Bivariate analysis compared patients with and without psychiatric co-morbidity, which was defined as prior diagnosis by a healthcare provider or acute psychiatric consultation for new or chronic mental illness. HRQL metrics included the EuroQol-5D-5L (EQ-5D) questionnaire, visual analogue scale (EQ-VAS), and overall index score. A multiple linear regression model was utilized to identify predictors of EQ-5D index scores. RESULTS Analysis of baseline characteristics revealed significantly greater rates of substance abuse, severe extremity injuries, inpatient morbidity, and hospital length-of-stay among patients with psychiatric illness. At 1-year follow-up, patients with psychiatric co-morbidity had lower median EQ-5D index scores compared to the control group (0.71, interquartile range [IQR] 0.32 vs. 0.79, IQR 0.22, p = 0.03). There were no differences between groups in individual EQ-5D dimensions, nor in EQ-VAS scores. Presence of psychiatric co-morbidity was not found to independently predict EQ-5D index scores in the linear regression model. Instead, Injury Severity Score (standardized regression coefficient [SRC] - 0.15, 95% confidence interval [CI] - 0.010 to - 0.001) and American Society of Anesthesiologists Physical Status score (SRC - 0.13, 95% CI - 0.08 to - 0.004) predicted poor HRQL 1-year after injury. CONCLUSIONS Psychiatric co-morbidity does not independently predict low HRQL 1 year after injury. Instead, lower HRQL scores among patients with psychiatric co-morbidity appear to be mediated by baseline health status and injury severity.
Collapse
Affiliation(s)
- Maximilian A Meyer
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Orthopedic Surgery, Massachusetts General Hospital, 55 Fruit Street, White Building 535, Boston, MA, 02114, USA.
| | - Tijmen van den Bosch
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marilyn Heng
- Department of Orthopedic Surgery, Massachusetts General Hospital, 55 Fruit Street, White Building 535, Boston, MA, 02114, USA
| | - Loek P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Marjan Kromkamp
- Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stijn D Nelen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
3
|
Hirot F, Ali A, Azouvi P, Naddaf A, Huas C, Guillaume S, Godart N. Five-year mortality after hospitalisation for suicide attempt with a violent method. J Psychosom Res 2022; 159:110949. [PMID: 35667157 DOI: 10.1016/j.jpsychores.2022.110949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study aimed to estimate the 5-year mortality among people admitted into a transdisciplinary unit providing combined psychiatric and somatic rehabilitation treatment. METHODS In this retrospective study, we analyzed the clinical records of all individuals admitted into the transdisciplinary unit from 01/01/2011 to 12/31/2017 after a suicide attempt using violent means. Vital status was ascertained for these 215 people, a standardized mortality ratio (SMR) was calculated and Log-rank tests were used to identify factors associated with mortality. RESULTS The crude mortality rate was 5.12% (11 deaths) and the SMR was 15.45 (95% CI = [7.71-27.65]; p < 0.001) 5.40 years after admission into the transdisciplinary unit. Factors associated with mortality were: older age (29.91 years versus 25.30 years, p < 0.001), a longer stay in acute care (p = 0.002) and a shorter stay in the transdisciplinary unit (p < 0.001). CONCLUSION Long-term mortality among people who have attempted suicide using violent means is 15 times higher than in the corresponding general young adult population. This study supports the hypothesis that the severity of a suicide attempt is associated with subsequent excess mortality. Therefore, there is a need to consolidate outpatient facilities that provide appropriate support for this specific population after discharge. These programmes need to ensure the continuity of coordinated psychiatric and somatic care and psychosocial rehabilitation in order to prevent the risk of suicide.
Collapse
Affiliation(s)
- France Hirot
- INSERM, UMR 1018, Centre de Recherche en Épidémiologie et Santé des Populations (CESP), Université Paris-Saclay. Villejuif, France; Fondation Santé des Etudiants de France (FSEF), Service hospitalo-universitaire de Santé Mentale de l'Adolescent et du Jeune Adulte (SMAJA), Paris, France.
| | - Aminata Ali
- INSERM, UMR 1018, Centre de Recherche en Épidémiologie et Santé des Populations (CESP), Université Paris-Saclay. Villejuif, France; Fondation Santé des Etudiants de France (FSEF), Service hospitalo-universitaire de Santé Mentale de l'Adolescent et du Jeune Adulte (SMAJA), Paris, France.
| | - Philippe Azouvi
- INSERM, UMR 1018, Centre de Recherche en Épidémiologie et Santé des Populations (CESP), Université Paris-Saclay. Villejuif, France; Université Versailles Saint-Quentin-en-Yvelines, UFR Simone Veil-Santé, Montigny-le-Bretonneux, France; APHP - Hôpital Raymond Poincaré, Service de Médecine Physique et de Réadaptation, Garches, France.
| | - Adrien Naddaf
- Fondation Santé des Etudiants de France (FSEF), Service hospitalo-universitaire de Santé Mentale de l'Adolescent et du Jeune Adulte (SMAJA), Paris, France.
| | - Caroline Huas
- INSERM, UMR 1018, Centre de Recherche en Épidémiologie et Santé des Populations (CESP), Université Paris-Saclay. Villejuif, France; Fondation Santé des Etudiants de France (FSEF), Service hospitalo-universitaire de Santé Mentale de l'Adolescent et du Jeune Adulte (SMAJA), Paris, France.
| | - Sébastien Guillaume
- Centre Hospitalier Universitaire De Montpellier, Service Urgence et Post-urgence psychiatrique, Montpellier, France; Université Montpellier 1, 34006 Montpellier, France; INSERM, U888, 34093 Montpellier, France.
| | - Nathalie Godart
- INSERM, UMR 1018, Centre de Recherche en Épidémiologie et Santé des Populations (CESP), Université Paris-Saclay. Villejuif, France; Fondation Santé des Etudiants de France (FSEF), Service hospitalo-universitaire de Santé Mentale de l'Adolescent et du Jeune Adulte (SMAJA), Paris, France; Université Versailles Saint-Quentin-en-Yvelines, UFR Simone Veil-Santé, Montigny-le-Bretonneux, France.
| |
Collapse
|
4
|
Yoo JI, Cha Y, Kim JT, Park CH, Choy W, Koo KH. Orthopedic Patients with Mental Disorder: Literature Review on Preoperative and Postoperative Precautions. Clin Orthop Surg 2022; 14:155-161. [PMID: 35685973 PMCID: PMC9152889 DOI: 10.4055/cios21156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/28/2022] [Accepted: 04/04/2022] [Indexed: 11/28/2022] Open
Abstract
Because of the increasing global trend of patients with mental disorders, orthopedic surgeons are more likely to encounter orthopedic patients with mental disorders in clinical settings. Identifying the characteristics of these patients and implementing psychiatric management can affect the clinical outcome of orthopedic treatment. Thus, orthopedic surgeons need to assess the psychiatric medical history of orthopedic patients with mental disorders before surgery and understand the psychological and behavioral patterns of patients with mental disorders. In addition, appropriate psychiatric consultations and evaluations are necessary to prevent worsening of mental disorders before and after surgery.
Collapse
Affiliation(s)
- Jun-Il Yoo
- Department of Orthopedic Surgery, Gyeongsang National University Hospital, Jinju, Korea
| | - Yonghan Cha
- Department of Orthopedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Jung-Taek Kim
- Department of Orthopedic Surgery, Ajou Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Chan Ho Park
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Korea
| | - Wonsik Choy
- Department of Orthopedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| |
Collapse
|
5
|
van Schijndel MA, van Wijngaarden JDH, van de Klundert JJ. Organization and Outcomes of Integrated Inpatient Medical and Psychiatric Care Units: A Systematic Review. Psychiatr Serv 2022; 73:64-76. [PMID: 34407632 DOI: 10.1176/appi.ps.202000416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The goal of this review was to assess the relationships among aims, designs, and outcomes of integrated inpatient medical and psychiatric care units (IMPUs) and gather the evidence base on the effectiveness of these units. METHODS Using online searches of Embase, Medline, Web of Science, PsycINFO, Scopus, CINAHL, Cochrane, and Google Scholar, the authors identified and reviewed literature describing the aims and outcomes of specific IMPU designs. RESULTS The search yielded 55 studies, in which the authors identified 39 IMPUs that focused on patients with mood, psychotic, somatic symptom, substance use, organic, and personality disorders and a broad array of medical diagnoses. Most units were psychiatric-medical units and had medium medical and psychiatric acuity capabilities. The studies reviewed provided little information on the cost-effectiveness of various IMPU designs. Although some comparative studies indicated reductions in hospital length of stay (LOS), these studies were generally of low quality and rarely reported other intended outcomes. CONCLUSIONS IMPUs may help shorten LOS. IMPUs should focus care on patients with complex conditions and high acuity to maximize health system value. Implementing compulsory admission facilities; qualified psychiatric, medical, and nursing staff involvement; and cross-disciplinary training may improve IMPUs' capacity to treat high-acuity patients. Future research should relate IMPU designs to intended outcomes.
Collapse
Affiliation(s)
- Maarten A van Schijndel
- Rijnstate Hospital, Arnhem, the Netherlands (van Schijndel); Erasmus MC, University Medical Center, Rotterdam, the Netherlands (van Schijndel); Erasmus School of Health Policy and Management, Rotterdam, the Netherlands (van Wijngaarden, van de Klundert); Prince Mohammed Bin Salman College of Business and Entrepreneurship, King Abdullah Economic City, Saudi Arabia (van de Klundert)
| | - Jeroen D H van Wijngaarden
- Rijnstate Hospital, Arnhem, the Netherlands (van Schijndel); Erasmus MC, University Medical Center, Rotterdam, the Netherlands (van Schijndel); Erasmus School of Health Policy and Management, Rotterdam, the Netherlands (van Wijngaarden, van de Klundert); Prince Mohammed Bin Salman College of Business and Entrepreneurship, King Abdullah Economic City, Saudi Arabia (van de Klundert)
| | - Joris J van de Klundert
- Rijnstate Hospital, Arnhem, the Netherlands (van Schijndel); Erasmus MC, University Medical Center, Rotterdam, the Netherlands (van Schijndel); Erasmus School of Health Policy and Management, Rotterdam, the Netherlands (van Wijngaarden, van de Klundert); Prince Mohammed Bin Salman College of Business and Entrepreneurship, King Abdullah Economic City, Saudi Arabia (van de Klundert)
| |
Collapse
|
6
|
Nishimura T, Naito H, Nakao A, Nakayama S. Characteristics of self-inflicted injury among suicidal patients: analysis of nation-wide trauma registry. Trauma Surg Acute Care Open 2021; 6:e000694. [PMID: 33912687 PMCID: PMC8031701 DOI: 10.1136/tsaco-2021-000694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/26/2021] [Accepted: 03/24/2021] [Indexed: 11/04/2022] Open
Abstract
Purpose Self-inflicted injury is one of the most common causes of suicide. Extremity injury is thought to occur most frequently among penetrating injury; however, epidemiology among patients attempting suicide is unknown. This study aims to find the characteristics of penetrating self-inflicted trauma patients. Methods This is a retrospective cohort study of Japanese nation-wide trauma registry (the Japan National Trauma Data Bank) between January 1, 2004 and December 31, 2017. Patients who attempted suicide with penetrating injury were eligible. We evaluated the occurrence of injury based on injury site (neck/face, chest, abdomen, extremity) as a dependent variable and aging as an independent variable using a generalized linear model and compare those groups with spline models. Results 4576 trauma patients were eligible. Excluding patients with missing age, missing survival data, and missing abbreviate injury score, 4183 patients were enrolled in this study. Common injury site is follows: abdomen 1772 patients (42.4%), extremity 1344 patients (32.0%), neck/face 1253 patients (30.0%), and chest 993 patients (23.7%). The occurrence of neck/face injury, chest injury, and abdominal injury increased with age. On contrary, the rate of extremity injury decreased with age. Conclusions Among self-inflicted trauma patients, abdominal injury was the most common injury, and neck/face injury, chest injury, and abdominal injury were related with aging. On the contrary, the rate of extremity injury decreased as patients' age progressed. Level of evidence Retrospective cohort study, Level III.
Collapse
Affiliation(s)
- Takeshi Nishimura
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan.,Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromichi Naito
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Atsunori Nakao
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinichi Nakayama
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| |
Collapse
|
7
|
Todorova L, Johansson A, Ivarsson B. Perceptions of ambulance nurses on their knowledge and competence when assessing psychiatric mental illness. Nurs Open 2021; 8:946-956. [PMID: 33570281 PMCID: PMC7877124 DOI: 10.1002/nop2.703] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/10/2020] [Accepted: 10/28/2020] [Indexed: 12/05/2022] Open
Abstract
AIMS AND OBJECTIVES To obtain the current perception of the knowledge and competence of pre-hospital emergency specialist nurses (ambulance) in attending patients with psychiatric symptoms. BACKGROUND Psychiatric illnesses have increased throughout the population. Consequently, pre-hospital emergency services frequently attend individuals with suspected or known mental illnesses. DESIGN We employed a set of quantitative and qualitative methods to gain a deeper understanding of ambulance nurses' self-evaluated knowledge. METHODS Seven ambulance nurses received and completed a survey questionnaire prior commencing employment in November 2019. Then, we conducted interviews to explore ambulance nurses' perceptions of their own knowledge and competence when attending individuals with mental disorders. The surveys were analysed with descriptive statistics, followed by content analysis. RESULTS Three topics emerged: the encounter of patients with mental illness; the awareness of lacking knowledge about mental illnesses; and the expectations for future Prehospital Emergency Psychiatric Response Teams. Although ambulance nurses already possessed basic knowledge regarding psychiatric illnesses, it was insufficient, based on their perception of appropriate care. Ambulance nurses considered that combining pre-hospital and psychiatric expertise in the pre-hospital emergency unit would increase their in-depth knowledge about various psychiatric illnesses, the treatment options and the alternatives regarding where to deliver patients for continued care.
Collapse
Affiliation(s)
- Lizbet Todorova
- Office of Medical ServicesRegion SkaneMalmöSweden
- Department of Clinical ScienceLund UniversityLundSweden
| | - Anders Johansson
- Office of Medical ServicesRegion SkaneMalmöSweden
- Department of Clinical ScienceLund UniversityLundSweden
| | - Bodil Ivarsson
- Office of Medical ServicesRegion SkaneMalmöSweden
- Department of Clinical ScienceLund UniversityLundSweden
- Department of Cardiothoracic SurgeryIKVLLund UniversityLundSweden
| |
Collapse
|
8
|
Faggiani M, Aragno E, Aprato A, Rosso G, Conforti LG, Maina G, Massè A. Falls from height: orthopaedic and psychiatric evaluation. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:79-84. [PMID: 32555080 PMCID: PMC7944834 DOI: 10.23750/abm.v91i4-s.9366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 03/19/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Fall from a height is one of the major causes of significant trauma with high morbidity and mortality rates. Traumatological damage control is often the primary treatment both for suicide attempt survivors and for accidental fall victims, but management of the hospitalization of psychiatric patients requires more resources than other patients. METHODS Retrospective multidisciplinary study (psychiatric and orthopaedic evaluation) and analysis of psychiatric and trauma characteristics of patients fallen from height admitted to our trauma centre. We analysed patterns of patients after suicidal jumps and accidental falls to look for possible trends that may trigger projects for further improvement of care. RESULTS 205 patients were analysed, 137 were included: 65 suicide attempt survivors and 72 accidental fall victims. Between these two groups there are no differences about the anaesthesiologic acute management or the number of damage control procedures. However, the psychiatric patients stay longer in hospital especially in intensive care unit with prolonged intubation (p<0.001). Suicide attempt survivors are significant correlated with fractures of feet, but the orthopaedic lesions do not involve an increase of definitive interventions (p< 0.05). CONCLUSION We showed that the suicide attempt survivors and accidental victims need the same acute management. The orthopedic definitive surgical procedures are similar between the two groups, but in spite of this patients with psychiatric disorder were associated with a statistically significant increase of care in intensive care unit and hospitalization. Our results allow to create a new multidisciplinary approach for these patients.
Collapse
Affiliation(s)
- Marianna Faggiani
- 1. Department of Orthopedics and Traumatology, C.T.O., Città della Salute e della Scienza, Turin, TO, Italy..
| | - Elena Aragno
- Department of Neurosciences "Rita Levi Montalcini", University of Turin, Italy.
| | - Alessandro Aprato
- 1. Department of Orthopedics and Traumatology, C.T.O., Città della Salute e della Scienza, Turin, TO, Italy..
| | - Gianluca Rosso
- Department of Neurosciences "Rita Levi Montalcini", University of Turin, Italy. San Luigi Gonzaga University Hospital of Orbassano (Turin), Italy..
| | - Luigi Giulio Conforti
- 1. Department of Orthopedics and Traumatology, C.T.O., Città della Salute e della Scienza, Turin, TO, Italy..
| | - Giuseppe Maina
- Department of Neurosciences "Rita Levi Montalcini", University of Turin, Italy. San Luigi Gonzaga University Hospital of Orbassano (Turin), Italy..
| | - Alessandro Massè
- 1. Department of Orthopedics and Traumatology, C.T.O., Città della Salute e della Scienza, Turin, TO, Italy.
| |
Collapse
|