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Qi F, Fan L, Wang C, Liu Y, Yang S, Fan Z, Miao F, Kan M, Feng K, Wang T. Index of consciousness monitoring during general anesthesia may effectively enhance rehabilitation in elderly patients undergoing laparoscopic urological surgery: a randomized controlled clinical trial. BMC Anesthesiol 2023; 23:331. [PMID: 37794331 PMCID: PMC10548750 DOI: 10.1186/s12871-023-02300-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/27/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Based on electroencephalogram (EEG) analysis, index of consciousness (IoC) monitoring is a new technique for monitoring anesthesia depth. IoC is divided into IoC1 (depth of sedation) and IoC2 (depth of analgesia). The potential for concurrent monitoring of IoC1 and IoC2 to expedite postoperative convalescence remains to be elucidated. We investigated whether combined monitoring of IoC1 and IoC2 can effectively enhances postoperative recovery compared with bispectral index (BIS) in elderly patients undergoing laparoscopic urological surgery under general anesthesia. METHODS In this prospective, controlled, double-blinded trail, 120 patients aged 65 years or older were arbitrarily assigned to either the IoC group or the control group (BIS monitoring). All patients underwent blood gas analysis at T1 (before anesthesia induction) and T2 (the end of operation). The Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were administered to all patients at T0 (1 day before surgery) and T4 (7 days after surgery). Serum concentrations of C-reactive protein (CRP) and glial fibrillary acid protein (GFAP) were assessed at T1, T2, and T3 (24 h after surgery). Postoperative complications and the duration of hospitalization were subjected to comparative evaluation. RESULTS The incidence of postoperative cognitive dysfunction (POCD) was notably lower in the IoC group (10%) than in the control group (31.7%) (P = 0.003). Postoperative serum CRP and GFAP concentrations exhibited significant differences at time points T2 (CRP: P = 0.000; GFAP: P = 0.000) and T3 (CRP: P = 0.003; GFAP: P = 0.008). Postoperative blood glucose levels (P = 0.000) and the overall rate of complications (P = 0.037) were significantly lower in Group IoC than in Group control. CONCLUSION The employment of IoC monitoring for the management of elderly surgical patients can accelerate postoperative convalescence by mitigating intraoperative stress and reducing peripheral and central inflammatory injury. TRIAL REGISTRATION Chinese Clinical Trial Registry Identifier: ChiCTR1900025241 (17/08/2019).
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Affiliation(s)
- Fengling Qi
- Department of Anesthesiology and Operating Theatre, Xuanwu Hospital, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, China
- Department of Anesthesiology, The First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou, China
| | - Long Fan
- Department of Anesthesiology and Operating Theatre, Xuanwu Hospital, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, China
| | - Chunxiu Wang
- Department of Evidence-based Medicine, Xuanwu Hospital, National Clinical Research Center of Geriatric Diseases, Capital Medical University, Beijing, China
| | - Yang Liu
- Department of Anesthesiology and Operating Theatre, Xuanwu Hospital, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, China
| | - Shuyi Yang
- Department of Anesthesiology and Operating Theatre, Xuanwu Hospital, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, China
| | - Zhen Fan
- Department of Anesthesiology and Operating Theatre, Xuanwu Hospital, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, China
| | - Fangfang Miao
- Department of Anesthesiology and Operating Theatre, Xuanwu Hospital, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, China
| | - Minhui Kan
- Department of Anesthesiology and Operating Theatre, Xuanwu Hospital, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, China
| | - Kunpeng Feng
- Department of Anesthesiology and Operating Theatre, Xuanwu Hospital, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, China
| | - Tianlong Wang
- Department of Anesthesiology and Operating Theatre, Xuanwu Hospital, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing, China.
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Zhou S, Hu H, Ru J. Efficacy and safety of sugammadex sodium in reversing rocuronium-induced neuromuscular blockade in children: An updated systematic review and meta-analysis. Heliyon 2023; 9:e18356. [PMID: 37520945 PMCID: PMC10374931 DOI: 10.1016/j.heliyon.2023.e18356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023] Open
Abstract
Objective In response to the differences in pharmacodynamic and pharmacokinetic characteristics of neuromuscular blocking agents between children and adults and limited studies which existing meta-analyses included, this study will update the safety and efficacy of sugammadex (Sug) sodium in reversing rocuronium-induced neuromuscular blockade in children. Methods Five electronic databases were searched for clinical trials on the safety and efficacy of Sug sodium in reversing rocuronium-induced neuromuscular block in children. A random-effects model was used to calculate the standardized mean difference (SMD) for primary outcomes. The relative risk (RR) was calculated for secondary outcomes. Results As of 2022-11-03, 18 out of 236 studies included 724 children in the intervention group and 478 children in the control group for meta-analysis. The results showed that compared with the control group, the time required for Train-of-Four Ratio (TOFR) to return to 0.9 and the extubation time were shortened in both 2 mg/kg and 4 mg/kg of Sug sodium, with statistically significant differences (TOFR ≥0.9: 2 mg/kg: SMD = -2.90; 95%CI: -3.75, -2.04; 4 mg/kg: -3.31; -4.79, -1.84; extubation time: 2 mg/kg: -2.95; -4.04, -1.85; 4 mg/kg: -1.57; -1.90, -1.23). Compared with the control group, the total incidence of adverse effects in the Sug group was lower (RR = 0.44; 0.24,0.82). Conclusions This review and meta-analysis suggest that Sug sodium is more effective and safer in reversing rocuronium-induced neuromuscular blockade in children than traditional antagonistic regimens or placebos.
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Affiliation(s)
- Sheng Zhou
- Department of Anesthesiology, Changzhou No.2 People's Hospital, Changzhou, Jiangsu, China
| | - Haiying Hu
- General Surgery Department, Changzhou West Taihu Hospital, Changzhou, Jiangsu, China
| | - Jianfen Ru
- Department of Anesthesiology, Changzhou No.2 People's Hospital, Changzhou, Jiangsu, China
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Ji S, Cho S, Jang Y, Kim E, Lee J, Kim J, Kim H. Pupil response to painful stimuli during inhalation anaesthesia without opioids in children. Acta Anaesthesiol Scand 2022; 66:803-810. [PMID: 35403238 DOI: 10.1111/aas.14071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/21/2022] [Accepted: 03/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pupil dilation reflex measured by a pupillometer is known to be a useful parameter for assessing the response to perioperative noxious stimuli. In children, pupillometer can reflect changes after painful stimuli during anaesthesia or guide anaesthesia to reduce opioid consumption. However, to date, there are no data regarding pupil response during inhalation anaesthesia with analgesia by intravenous acetaminophen in children. METHODS We planned a prospective, single-armed study of children aged between 3 and 12 years who underwent surgery under general anaesthesia. Anaesthesia was maintained by 1 minimum alveolar concentration (MAC) of sevoflurane, and 15 mg/kg of acetaminophen was administered. Patients' left eye was examined using a pupillometer after induction, before and after skin incision and train-of-four stimulus. Pupil diameter and other pupillometric parameters were recorded. Increase in heart rate by 15% was regarded as insufficient analgesia to skin incision and indicative powers of pupillometric parameters for insufficient analgesia were examined by receiver-operating characteristics. RESULTS A total of 33 patients were included. Enlarged pupil, large increase in pupil diameter and low neurological pupil index (NPi) after skin incision were good indicators of insufficient analgesia for skin incision. Children with insufficient analgesia showed abnormal NPi value. However, increase in pupil diameter and decrease in NPi were observed even in patients without increase in the heart rate after the skin incision. CONCLUSIONS We suggest dilation of the pupil and decrease in NPi can indicate response to noxious stimuli in children. Regardless of sufficiency of analgesia, pupil dilation and decrease in NPi were observed after skin incision in children under general anaesthesia with 1 MAC of sevoflurane and intravenous acetaminophen.
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Affiliation(s)
- Sang‐Hwan Ji
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital Seoul National University College of Medicine Seoul Republic of Korea
| | - Sung‐Ae Cho
- Department of Anaesthesiology and Pain Medicine, Konyang University Hospital Konyang University College of Medicine Daejeon Republic of Korea
| | - Young‐Eun Jang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital Seoul National University College of Medicine Seoul Republic of Korea
| | - Eun‐Hee Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital Seoul National University College of Medicine Seoul Republic of Korea
| | - Ji‐Hyun Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital Seoul National University College of Medicine Seoul Republic of Korea
| | - Jin‐Tae Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital Seoul National University College of Medicine Seoul Republic of Korea
| | - Hee‐Soo Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital Seoul National University College of Medicine Seoul Republic of Korea
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Oxidative stress under general intravenous and inhalation anaesthesia. Arh Hig Rada Toksikol 2020; 71:169-177. [PMID: 33074169 PMCID: PMC7968496 DOI: 10.2478/aiht-2020-71-3437] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/01/2020] [Indexed: 01/23/2023] Open
Abstract
Oxidative stress occurs when reactive oxygen species (ROS) production overwhelms cell protection by antioxidants. This review is focused on general anaesthesia-induced oxidative stress because it increases the rate of complications and delays recovery after surgery. It is important to know what effects of anaesthetics to expect in terms of oxidative stress, particularly in surgical procedures with high ROS production, because their either additive or antagonistic effect may be pivotal for the outcome of surgery. In vitro and animal studies on this topic are numerous but show large variability. There are not many human studies and what we know has been learned from different surgical procedures measuring different endpoints in blood samples taken mostly before and after surgery. In these studies most intravenous anaesthetics have antioxidative properties, while volatile anaesthetics temporarily increase oxidative stress in longer surgical procedures.
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Meyers RS, Thackray J, Matson KL, McPherson C, Lubsch L, Hellinga RC, Hoff DS. Key Potentially Inappropriate Drugs in Pediatrics: The KIDs List. J Pediatr Pharmacol Ther 2020; 25:175-191. [PMID: 32265601 DOI: 10.5863/1551-6776-25.3.175] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The safe use of medications in pediatric patients requires practitioners to consider the unique pharmacokinetics and pharmacodynamics of drugs prescribed in this age group. In an effort to create a standard of care for the safe use of medications in this population, a list of drugs that are potentially inappropriate for use in pediatric patients has been developed and titled the "KIDs List." METHODS A panel of 7 pediatric pharmacists from the Pediatric Pharmacy Association were recruited to evaluate primary, secondary, and tertiary literature; FDA Pediatric Safety Communications; the Lexicomp electronic database; and product information for drugs that should be considered potentially inappropriate for use in pediatric patients. Information was rated using predefined criteria. A PubMed search was conducted using the following terms: adverse drug events OR adverse drug reactions. The search was limited to humans; age <18 years; case reports, observational studies, or clinical trials; and English language. No date range was used. Results were used to create an evidence-based list of candidate drugs that was then peer-reviewed and subjected to a 30-day public comment period prior to being finalized. RESULTS A PubMed search yielded 4049 unique titles, of which 210 were deemed relevant for full review. Practitioner recommendations highlighted an additional 77 drugs. FDA Pediatric Safety Communications and the Lexicomp database yielded 22 and 619 drugs, respectively. After critical analysis, peer review, and public review the final KIDs List contains 67 drugs and/or drug classes and 10 excipients. CONCLUSIONS This extensive effort led to compilation of the first list of drugs that are potentially inappropriate for prescribing in all or in a select subgroup of pediatric patients. If avoidance is not clinically possible, the drug should be used with caution and accompanied by appropriate monitoring.
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Utility of a Team-Based Multimodal Opioid Reduction Protocol for the Pediatric Plastic Surgery Population. Ann Plast Surg 2020; 84:S283-S287. [PMID: 31972573 DOI: 10.1097/sap.0000000000002208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Opioid use can cause significant adverse side effects with increased propensity toward both short- and long-term complications in the pediatric population. We present a multifaceted opioid reduction protocol based on physician and care team member education. The strategy was designed to alter prescribing practices, improve preoperative and postoperative patient education, increase the use of nonnarcotic pain control modalities, and improve coordination of opiate reduction strategies for all team members participating in patient care. We present the utility of this strategy in limiting postoperative narcotic use in the pediatric plastic surgery population.A prospective study with historical controls was conducted to evaluate pediatric patients undergoing elective pediatric plastic surgery procedures at 3-month intervals in 2016, 2017, and 2018. In the final year, the dedicated opiate reduction protocol was implemented before the data collection period, and results were compared with the prior 2 collection periods. The primary outcomes were total days and doses of outpatient narcotics prescribed after surgery.The median days (quartiles) of opioids prescribed in 2016, 2017, and 2018 cohorts were 1.5 (1.1, 2.5) days, 1.5 (1.4, 2.5) days, and 0.8 (0, 1.6) days, respectively. The median doses (quartiles) of opioids prescribed in 2016, 2017, and 2018 cohorts were 6.3 (6, 10), 6.0 (5.7, 15.0), and 4.2 (0, 6.2) doses, respectively. There were statistically significantly less days and doses of opioids prescribed in the 2018 cohort when compared with the 2016 (P < 0.0001) and 2017 (P < 0.0001) cohorts.A multimodal opioid reduction protocol was successfully implemented for the pediatric plastic surgery population. Patients were able to shorten the duration of narcotic prescription upon discharge with the use of a multidisciplinary team approach.
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Miller KA, Andolfatto G, Miner JR, Burton JH, Krauss BS. Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update. Ann Emerg Med 2019; 73:470-480. [DOI: 10.1016/j.annemergmed.2018.12.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022]
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Julien-Marsollier F, Rachdi K, Caballero MJ, Ayanmanesh F, Vacher T, Horlin AL, Skhiri A, Brasher C, Michelet D, Dahmani S. Evaluation of the analgesia nociception index for monitoring intraoperative analgesia in children. Br J Anaesth 2018; 121:462-468. [PMID: 30032886 DOI: 10.1016/j.bja.2018.03.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/27/2018] [Accepted: 04/26/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Intraoperative analgesia is still administered without guidance. Anaesthetists decide upon dosing on the basis of mean population opioid pharmacological studies and in response to variations in haemodynamic status. However, those techniques have been shown to be imprecise. We assessed the diagnostic value of monitoring the analgesia nociception index (ANI) to detect surgical stimulation in children. METHODS This was an observational study of 2- to 12-yr-old patients 5 min before and after surgical incision. Hypnosis was maintained with sevoflurane and guided by bispectral index. Intraoperative analgesia was administered as a remifentanil infusion titrated to variations in haemodynamic parameters, and ANI monitor values were recorded. ANI parameters assessed included instantaneous ANI (ANIi), mean ANI (ANIm), and the relative change of ANIi to ANIm (DeltaANI=ANIi-ANIm/ANIm). Statistical analyses were performed using receiver-operating-characteristic analysis with determination of the area under the receiver operating characteristic (AUROC) curve and the grey zone. RESULTS Overall, 49 subjects were included in this study. The AUROC was 0.755 (0.738-0.772), 0.771 (0.755-0.787), and 0.756 (0.738-0.774) for ANIi, ANIm, and DeltaANI, respectively. The threshold of ANI parameters indicating the presence of noxious surgical stimuli was ≤53%, ≤56%, and ≤-13.3% for ANIi, ANIm, and DeltaANI, respectively. The percentage of subjects in the inconclusive zone was 41%, 51%, and 33% for ANIi, ANIm, and DeltaANI, respectively. CONCLUSIONS ANI has diagnostic value for detecting surgical stimuli in children.
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Affiliation(s)
- F Julien-Marsollier
- Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Paris, France; Denis Diderot University, Paris, France; DHU Protect INSERM U 1141, Robert Debré University Hospital, Paris, France
| | - K Rachdi
- Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Paris, France
| | - M-J Caballero
- Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Paris, France; Denis Diderot University, Paris, France; DHU Protect INSERM U 1141, Robert Debré University Hospital, Paris, France
| | - F Ayanmanesh
- Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Paris, France; Denis Diderot University, Paris, France; DHU Protect INSERM U 1141, Robert Debré University Hospital, Paris, France
| | - T Vacher
- Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Paris, France; Denis Diderot University, Paris, France; DHU Protect INSERM U 1141, Robert Debré University Hospital, Paris, France
| | - A-L Horlin
- Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Paris, France; Denis Diderot University, Paris, France; DHU Protect INSERM U 1141, Robert Debré University Hospital, Paris, France
| | - A Skhiri
- Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Paris, France; Denis Diderot University, Paris, France; DHU Protect INSERM U 1141, Robert Debré University Hospital, Paris, France
| | - C Brasher
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Australia; Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - D Michelet
- Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Paris, France; Paris Descartes University, Paris, France
| | - S Dahmani
- Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Paris, France; Denis Diderot University, Paris, France; DHU Protect INSERM U 1141, Robert Debré University Hospital, Paris, France.
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Vasquez A, Farias-Moeller R, Tatum W. Pediatric refractory and super-refractory status epilepticus. Seizure 2018; 68:62-71. [PMID: 29941225 DOI: 10.1016/j.seizure.2018.05.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/17/2018] [Accepted: 05/19/2018] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To summarize the available evidence related to pediatric refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE), with emphasis on epidemiology, etiologies, therapeutic approaches, and clinical outcomes. METHODS Narrative review of the medical literature using MEDLINE database. RESULTS RSE is defined as status epilepticus (SE) that fails to respond to adequately used first- and second-line antiepileptic drugs. SRSE occurs when SE persist for 24 h or more after administration of anesthesia, or recurs after its withdrawal. RSE and SRSE represent complex neurological emergencies associated with long-term neurological dysfunction and high mortality. Challenges in management arise as the underlying etiology is not always promptly recognized and therapeutic options become limited with prolonged seizures. Treatment decisions mainly rely on case series or experts' opinions. The comparative effectiveness of different treatment strategies has not been evaluated in large prospective series or randomized clinical trials. Continuous infusion of anesthetic agents is the most common treatment for RSE and SRSE, although many questions on optimal dosing and rate of administration remain unanswered. The use of non-pharmacological therapies is documented in case series or reports with low level of evidence. In addition to neurological complications resulting from prolonged seizures, children with RSE/SRSE often develop systemic complications associated with polypharmacy and prolonged hospital stay. CONCLUSION RSE and SRSE are neurological emergencies with limited therapeutic options. Multi-national collaborative efforts are desirable to evaluate the safety and efficacy of current RSE/SRSE therapies, and potentially impact patients' outcomes.
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Affiliation(s)
- Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Raquel Farias-Moeller
- Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, United States.
| | - William Tatum
- Department of Neurology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL, 32224, United States.
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