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Shuey MM, Xiang RR, Moss ME, Carvajal BV, Wang Y, Camarda N, Fabbri D, Rahman P, Ramsey J, Stepanian A, Sebastiani P, Wells QS, Beckman JA, Jaffe IZ. Systems Approach to Integrating Preclinical Apolipoprotein E-Knockout Investigations Reveals Novel Etiologic Pathways and Master Atherosclerosis Network in Humans. Arterioscler Thromb Vasc Biol 2022; 42:35-48. [PMID: 34758633 PMCID: PMC8887835 DOI: 10.1161/atvbaha.121.317071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Animal models of atherosclerosis are used extensively to interrogate molecular mechanisms in serial fashion. We tested whether a novel systems biology approach to integration of preclinical data identifies novel pathways and regulators in human disease. Approach and Results: Of 716 articles published in ATVB from 1995 to 2019 using the apolipoprotein E knockout mouse to study atherosclerosis, data were extracted from 360 unique studies in which a gene was experimentally perturbed to impact plaque size or composition and analyzed using Ingenuity Pathway Analysis software. TREM1 (triggering receptor expressed on myeloid cells) signaling and LXR/RXR (liver X receptor/retinoid X receptor) activation were identified as the top atherosclerosis-associated pathways in mice (both P<1.93×10-4, TREM1 implicated early and LXR/RXR in late atherogenesis). The top upstream regulatory network in mice (sc-58125, a COX2 inhibitor) linked 64.0% of the genes into a single network. The pathways and networks identified in mice were interrogated by testing for associations between the genetically predicted gene expression of each mouse pathway-identified human homolog with clinical atherosclerosis in a cohort of 88 660 human subjects. Homologous human pathways and networks were significantly enriched for gene-atherosclerosis associations (empirical P<0.01 for TREM1 and LXR/RXR pathways and COX2 network). This included 12(60.0%) TREM1 pathway genes, 15(53.6%) LXR/RXR pathway genes, and 67(49.3%) COX2 network genes. Mouse analyses predicted, and human study validated, the strong association of COX2 expression (PTGS2) with increased likelihood of atherosclerosis (odds ratio, 1.68 per SD of genetically predicted gene expression; P=1.07×10-6). CONCLUSIONS PRESCIANT (Preclinical Science Integration and Translation) leverages published preclinical investigations to identify high-confidence pathways, networks, and regulators of human disease.
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Affiliation(s)
| | | | - M. Elizabeth Moss
- Department of Medicine (M.M.S., J.R., Q.S.W., J.A.B.) and Department of Biomedical Informatics (D.F., P.R.), Vanderbilt University Medical Center, Nashville, TN. Molecular Cardiology Research Institute (R.R.X., M.E.M., B.V.C., Y.W., N.C., A.S., I.Z.J.) and Institute for Clinical Research and Health Policy Studies (P.S.), Tufts Medical Center, Boston, MA
| | - Brigett V. Carvajal
- Department of Medicine (M.M.S., J.R., Q.S.W., J.A.B.) and Department of Biomedical Informatics (D.F., P.R.), Vanderbilt University Medical Center, Nashville, TN. Molecular Cardiology Research Institute (R.R.X., M.E.M., B.V.C., Y.W., N.C., A.S., I.Z.J.) and Institute for Clinical Research and Health Policy Studies (P.S.), Tufts Medical Center, Boston, MA
| | - Yihua Wang
- Department of Medicine (M.M.S., J.R., Q.S.W., J.A.B.) and Department of Biomedical Informatics (D.F., P.R.), Vanderbilt University Medical Center, Nashville, TN. Molecular Cardiology Research Institute (R.R.X., M.E.M., B.V.C., Y.W., N.C., A.S., I.Z.J.) and Institute for Clinical Research and Health Policy Studies (P.S.), Tufts Medical Center, Boston, MA
| | - Nicholas Camarda
- Department of Medicine (M.M.S., J.R., Q.S.W., J.A.B.) and Department of Biomedical Informatics (D.F., P.R.), Vanderbilt University Medical Center, Nashville, TN. Molecular Cardiology Research Institute (R.R.X., M.E.M., B.V.C., Y.W., N.C., A.S., I.Z.J.) and Institute for Clinical Research and Health Policy Studies (P.S.), Tufts Medical Center, Boston, MA
| | - Daniel Fabbri
- Department of Medicine (M.M.S., J.R., Q.S.W., J.A.B.) and Department of Biomedical Informatics (D.F., P.R.), Vanderbilt University Medical Center, Nashville, TN. Molecular Cardiology Research Institute (R.R.X., M.E.M., B.V.C., Y.W., N.C., A.S., I.Z.J.) and Institute for Clinical Research and Health Policy Studies (P.S.), Tufts Medical Center, Boston, MA
| | - Protiva Rahman
- Department of Medicine (M.M.S., J.R., Q.S.W., J.A.B.) and Department of Biomedical Informatics (D.F., P.R.), Vanderbilt University Medical Center, Nashville, TN. Molecular Cardiology Research Institute (R.R.X., M.E.M., B.V.C., Y.W., N.C., A.S., I.Z.J.) and Institute for Clinical Research and Health Policy Studies (P.S.), Tufts Medical Center, Boston, MA
| | - Jacob Ramsey
- Department of Medicine (M.M.S., J.R., Q.S.W., J.A.B.) and Department of Biomedical Informatics (D.F., P.R.), Vanderbilt University Medical Center, Nashville, TN. Molecular Cardiology Research Institute (R.R.X., M.E.M., B.V.C., Y.W., N.C., A.S., I.Z.J.) and Institute for Clinical Research and Health Policy Studies (P.S.), Tufts Medical Center, Boston, MA
| | - Alec Stepanian
- Department of Medicine (M.M.S., J.R., Q.S.W., J.A.B.) and Department of Biomedical Informatics (D.F., P.R.), Vanderbilt University Medical Center, Nashville, TN. Molecular Cardiology Research Institute (R.R.X., M.E.M., B.V.C., Y.W., N.C., A.S., I.Z.J.) and Institute for Clinical Research and Health Policy Studies (P.S.), Tufts Medical Center, Boston, MA
| | - Paola Sebastiani
- Department of Medicine (M.M.S., J.R., Q.S.W., J.A.B.) and Department of Biomedical Informatics (D.F., P.R.), Vanderbilt University Medical Center, Nashville, TN. Molecular Cardiology Research Institute (R.R.X., M.E.M., B.V.C., Y.W., N.C., A.S., I.Z.J.) and Institute for Clinical Research and Health Policy Studies (P.S.), Tufts Medical Center, Boston, MA
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Ho KY, Cardosa MS, Chaiamnuay S, Hidayat R, Ho HQT, Kamil O, Mokhtar SA, Nakata K, Navarra SV, Nguyen VH, Pinzon R, Tsuruoka S, Yim HB, Choy E. Practice Advisory on the Appropriate Use of NSAIDs in Primary Care. J Pain Res 2020; 13:1925-1939. [PMID: 32821151 PMCID: PMC7422842 DOI: 10.2147/jpr.s247781] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/24/2020] [Indexed: 12/14/2022] Open
Abstract
Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks.
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Affiliation(s)
- Kok Yuen Ho
- The Pain Clinic, Mt Alvernia Hospital, Singapore
| | | | - Sumapa Chaiamnuay
- Rheumatic Disease Unit, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Rudy Hidayat
- Rheumatology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusomo Hospital, Jakarta, Indonesia
| | | | - Ozlan Kamil
- Gleneagles Hospital, Kuala Lumpur, Malaysia.,Prince Court Medical Center, Kuala Lumpur, Malaysia
| | - Sabarul A Mokhtar
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Ken Nakata
- Department of Health and Sport Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Sandra V Navarra
- Section of Rheumatology, Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Van Hung Nguyen
- Department of Rheumatology, Bach Mai Hospital, Hanoi, Vietnam
| | - Rizaldy Pinzon
- Department of Neurology, Faculty of Medicine, Kristen Duta Wacana University, Bethesda Hospital, Yogyakarta, Indonesia
| | | | - Heng Boon Yim
- Mount Elizabeth Novena Hospital, Singapore.,Faculty of Medicine, National University of Singapore, Singapore
| | - Ernest Choy
- Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
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Szeto CC, Sugano K, Wang JG, Fujimoto K, Whittle S, Modi GK, Chen CH, Park JB, Tam LS, Vareesangthip K, Tsoi KKF, Chan FKL. Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations. Gut 2020; 69:617-629. [PMID: 31937550 DOI: 10.1136/gutjnl-2019-319300] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/06/2019] [Accepted: 12/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications. OBJECTIVE To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs. METHODS Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations. RESULTS Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases. CONCLUSION NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong
| | - Kentaro Sugano
- Jichi Medical University, Shimotsuke, Tochigi, Japan.,Asian Pacific Association of Gastroenterology (APAGE), Tochigi, Japan
| | - Ji-Guang Wang
- Shanghai Institute of Hypertension, Shanghai, Shanghai, China.,Asia Pacific Society of Hypertension (APSH), Shanghai, China
| | - Kazuma Fujimoto
- Saga University, Saga, Japan.,Asia-Pacific Society for Digestive Endoscopy (APSDE), Saga, Japan
| | - Samuel Whittle
- The University of Adelaide, Adelaide, South Australia, Australia.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Gopesh K Modi
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Samarpan Kidney Institute and Research Center, Bhopal, India
| | - Chen-Huen Chen
- National Yang-Ming University, Taipei, Taiwan.,Pulse of Asia (PoA), Taipei, Taiwan
| | - Jeong-Bae Park
- Pulse of Asia (PoA), Taipei, Taiwan.,JB Lab and Clinic and Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Lai-Shan Tam
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, New Territories, Hong Kong.,Asia Pacific League of Associations for Rheumatology (APLAR), Adelaide, South Australia, Australia
| | - Kriengsak Vareesangthip
- Asian Pacific Society of Nephrology (APSN), Hong Kong, Hong Kong.,Mahidol University, Nakorn Pathom, Thailand
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González-Barnadas A, Camps-Font O, Martín-Fatás P, Figueiredo R, Gay-Escoda C, Valmaseda-Castellón E. Efficacy and safety of selective COX-2 inhibitors for pain management after third molar removal: a meta-analysis of randomized clinical trials. Clin Oral Investig 2019; 24:79-96. [DOI: 10.1007/s00784-019-02910-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 04/09/2019] [Indexed: 01/02/2023]
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Parkinson L, Waters DL, Franck L. Systematic review of the impact of osteoarthritis on health outcomes for comorbid disease in older people. Osteoarthritis Cartilage 2017; 25:1751-1770. [PMID: 28710026 DOI: 10.1016/j.joca.2017.07.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 05/28/2017] [Accepted: 07/05/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE A systematic review was undertaken examining the impact of comorbid osteoarthritis on health outcomes for people aged 50 years or older with cardiovascular disease, diabetes or obesity. DESIGN The protocol is registered in PROSPERO (CRD42015023417). Relevant electronic databases and grey literature were systematically searched for studies published in English between January 2005 and December 2016. Two reviewers independently screened studies for selection using predetermined inclusion and exclusion criteria, and independently completed methodological quality review. Data was extracted at study level by one reviewer and independently checked by a second reviewer, using a standardized form. The results across studies were qualitatively synthesized with outcomes described and summarized. RESULTS Of 1456 articles, we identified 15 relevant studies, with nine good to high quality studies describing significant negative impact of osteoarthritis on outcomes for cardiovascular diseases. There were too few studies focussing on diabetes and obesity to make conclusions in regard to these diseases. CONCLUSIONS This review provides evidence that osteoarthritis should not be overlooked when impacts of chronic disease on health outcomes and related health service use are considered. There is a clear need for more studies that consider the impacts of osteoarthritis on comorbid disease, especially those that consider the impact of osteoarthritis beyond the morbidity impacts. The management of comorbid osteoarthritis should be addressed for those with cardiovascular disease, and treatment choices considered given this association.
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Affiliation(s)
- L Parkinson
- Central Queensland University, Rockhampton, Australia.
| | - D L Waters
- University of Otago, Dunedin, New Zealand
| | - L Franck
- Central Queensland University, Rockhampton, Australia
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Gunter BR, Butler KA, Wallace RL, Smith SM, Harirforoosh S. Non-steroidal anti-inflammatory drug-induced cardiovascular adverse events: a meta-analysis. J Clin Pharm Ther 2016; 42:27-38. [DOI: 10.1111/jcpt.12484] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 10/26/2016] [Indexed: 01/07/2023]
Affiliation(s)
- B. R. Gunter
- Gatton College of Pharmacy; East Tennessee State University; Johnson City TN USA
| | - K. A. Butler
- Gatton College of Pharmacy; East Tennessee State University; Johnson City TN USA
| | - R. L. Wallace
- Quillen College of Medicine Library; East Tennessee State University; Johnson City TN USA
| | - S. M. Smith
- Division of Cardiology; Department of Internal Medicine; Quillen College of Medicine; East Tennessee State University; Johnson City TN USA
| | - S. Harirforoosh
- Department of Pharmaceutical Sciences; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN USA
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Bournia VK, Kitas G, Protogerou AD, Sfikakis PP. Impact of non-steroidal anti-inflammatory drugs on cardiovascular risk: Is it the same in osteoarthritis and rheumatoid arthritis? Mod Rheumatol 2016; 27:559-569. [PMID: 27659504 DOI: 10.1080/14397595.2016.1232332] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Although large-scale population studies have shown that non-steroidal anti-inflammatory drugs (NSAIDs) increase the risk of myocardial infarction, this is not confirmed in patients with rheumatoid arthritis (RA). Herein, we review the litterature on the differential effects of NSAIDs on cardiovascular risk in osteoarthritis (OA) versus RA and discuss possible explanations for this discrepancy. To assess a potential additive effect of age in non-RA populations, we compared weighted mean age between RA patients and unselected NSAID users included in cohort and case-control studies that estimate the cardiovascular risk of NSAIDs, assuming that the main indication for NSAID usage in elderly populations is OA. Our hypothesis that advanced age in osteoarthtitis compared to RA patients confounds the effect of NSAIDs on cardiovasular risk was not confirmed. Several other hypotheses that can be proposed to explain this counterintuitive effect of NSAIDs on the cardiovascular risk of RA patients are discussed. We conclude that patients with RA have a lower cardiovascular disease risk associated with the use of NSAIDs, probably due to the nature of their disease per se, until further research indicates differently.
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Affiliation(s)
- Vasiliki-Kalliopi Bournia
- a First Department of Propaedeutic and Internal Medicine and Joined Rheumatology Program , Medical School, National and Kapodistrian University of Athens, Laikon Hospital , Athens , Greece
| | - George Kitas
- a First Department of Propaedeutic and Internal Medicine and Joined Rheumatology Program , Medical School, National and Kapodistrian University of Athens, Laikon Hospital , Athens , Greece
| | - Athanasios D Protogerou
- a First Department of Propaedeutic and Internal Medicine and Joined Rheumatology Program , Medical School, National and Kapodistrian University of Athens, Laikon Hospital , Athens , Greece
| | - Petros P Sfikakis
- a First Department of Propaedeutic and Internal Medicine and Joined Rheumatology Program , Medical School, National and Kapodistrian University of Athens, Laikon Hospital , Athens , Greece
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Hoxha M, Buccellati C, Capra V, Garella D, Cena C, Rolando B, Fruttero R, Carnevali S, Sala A, Rovati G, Bertinaria M. In vitro pharmacological evaluation of multitarget agents for thromboxane prostanoid receptor antagonism and COX-2 inhibition. Pharmacol Res 2016; 103:132-43. [DOI: 10.1016/j.phrs.2015.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 11/15/2015] [Indexed: 11/29/2022]
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Bhosale UA, Quraishi N, Yegnanarayan R, Devasthale D. A cohort study to evaluate cardiovascular risk of selective and nonselective cyclooxygenase inhibitors (COX-Is) in arthritic patients attending orthopedic department of a tertiary care hospital. Niger Med J 2014; 55:417-22. [PMID: 25298608 PMCID: PMC4178340 DOI: 10.4103/0300-1652.140386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Cyclooxygenase-2 inhibitors (COX-2-Is) have recently been concerned in the occurrence of adverse cardiovascular (CV) events. Rofecoxib and valdecoxib has been withdrawn from the market, but celecoxib, etoricoxib and parecoxib continues to be used. Other nonsteroidal anti-inflammatory drugs (NSAIDs) may also increase the risk of CV events. However, clinical trial databases for COX-2-Is had created lots of controversies regarding cardiovascular safety of selective and nonselective cyclooxygenase inhibitors (COX-Is). This study was, conducted to assess and compare the CV risk of COX-Is in arthritic patients over a period of time. Materials and Methods: In this prospective cohort study adult arthritics of either sex those were freshly diagnosed or taking COX-Is for < 3 months; were included. Patients were grouped into nonselective and selective COX-2-I groups with reference to treatment they received. The CV risk factors like blood pressure (BP), blood sugar level (BSL), lipid profile, body mass index (BMI) were assessed and compared; demography of CV risk factors was also studied. Data obtained was analysed using Student's ‘t’-test of OpenEpi statistical software. Results: Study clearly revealed that all NSAIDs exhibit variable CV risk; however, selective COX-2-Is found to exhibit more CV risk. BMI, BP and lipid profile; the potential CV risk factors, showed significant impairment in selective COX-2-Is group; P < 0.01, P < 0.001 and P < 0.05, respectively, compared to baseline and P < 0.05 vs. nonselective COX-Is for BMI. Conclusions: This study portrays the potential CV risk of selective COX-2-Is; confirms and re-evaluate the results of earlier studies in this regard.
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Affiliation(s)
- Uma A Bhosale
- Department of Pharmacology, Smt. Kashibai Navale Medical College and General Hospital, Narhe, Pune, Maharashtra, India
| | - Nilofar Quraishi
- Department of Pharmacology, Smt. Kashibai Navale Medical College and General Hospital, Narhe, Pune, Maharashtra, India
| | - Radha Yegnanarayan
- Department of Pharmacology, Smt. Kashibai Navale Medical College and General Hospital, Narhe, Pune, Maharashtra, India
| | - Dileep Devasthale
- Department of Orthopedics, Smt. Kashibai Navale Medical College and General Hospital, Narhe, Pune, Maharashtra, India
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