1
|
Wakefield CJ, Baucom M, Sisak S, Seder CW, Janowak CF. Pectoralis Muscle Index as Predictor of Outcomes in Patients With Severe Blunt Chest Wall Injury. J Surg Res 2024; 300:247-252. [PMID: 38824855 DOI: 10.1016/j.jss.2024.04.013] [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: 12/30/2023] [Revised: 03/01/2024] [Accepted: 04/17/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Sarcopenia has been shown to portend worse outcomes in injured patients; however, little is known about the impact of thoracic muscle wasting on outcomes of patients with chest wall injury. We hypothesized that reduced pectoralis muscle mass is associated with poor outcomes in patients with severe blunt chest wall injury. METHODS All patients admitted to the intensive care unit between 2014 and 2019 with blunt chest wall injury requiring mechanical ventilation were retrospectively identified. Blunt chest wall injury was defined as the presence of one or more rib fractures as a result of blunt injury mechanism. Exclusion criteria included lack of admission computed tomography imaging, penetrating trauma, <18 y of age, and primary neurologic injury. Thoracic musculature was assessed by measuring pectoralis muscle cross-sectional area (cm2) that was obtained at the fourth thoracic vertebral level using Slice-O-Matic software. The area was then divided by the patient height in meters2 to calculate pectoralis muscle index (PMI) (cm2/m2). Patients were divided into two groups, 1) the lowest gender-specific quartile of PMI and 2) second-fourth gender-specific PMI quartiles for comparative analysis. RESULTS One hundred fifty-three patients met the inclusion criteria with a median (interquartile range) age 48 y (34-60), body mass index of 30.1 kg/m2 (24.9-34.6), and rib score of 3.0 (2.0-4.0). Seventy-five percent of patients (116/153) were male. Fourteen patients (8%) had prior history of chronic lung disease. Median (IQR) intensive care unit length-of-stay and duration of mechanical ventilation (MV) was 18.0 d (13.0-25.0) and 15.0 d (10.0-21.0), respectively. Seventy-three patients (48%) underwent tracheostomy and nine patients (6%) expired during hospitalization. On multivariate linear regression, reduced pectoralis muscle mass was associated with increased MV duration when adjusting for rib score and injury severity score (β 5.98, 95% confidence interval 1.28-10.68, P = 0.013). CONCLUSIONS Reduced pectoralis muscle mass is associated with increased duration of MV in patients with severe blunt chest wall injury. Knowledge of this can help guide future research and risk stratification of critically ill chest wall injury patients.
Collapse
Affiliation(s)
- Connor J Wakefield
- Brooke Army Medical Center, Department of Internal Medicine, Fort Sam Houston, Texas.
| | - Matthew Baucom
- University of Cincinnati Medical Center, Department of Trauma Surgery, Cincinnati, Ohio
| | - Stephanie Sisak
- University of Cincinnati Medical Center, Department of Trauma Surgery, Cincinnati, Ohio
| | - Christopher W Seder
- Rush University Medical Center, Department of Cardiovascular and Thoracic Surgery, Chicago, Illinois
| | - Christopher F Janowak
- University of Cincinnati Medical Center, Department of Trauma Surgery, Cincinnati, Ohio
| |
Collapse
|
2
|
Al-Taie A, Arueyingho O, Khoshnaw J, Hafeez A. Clinical outcomes of multidimensional association of type 2 diabetes mellitus, COVID-19 and sarcopenia: an algorithm and scoping systematic evaluation. Arch Physiol Biochem 2024; 130:342-360. [PMID: 35704400 DOI: 10.1080/13813455.2022.2086265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND The aim of this study was to provide a scoping and comprehensive review for the clinical outcomes from the cross-link of Type 2 diabetes mellitus (T2DM), COVID-19, and sarcopenia. METHODS By using PRISMA guidelines and searching through different databases that could provide findings of evidence on the association of T2DM, COVID-19, and sarcopenia. RESULTS Thirty-three studies reported a relationship between sarcopenia with T2DM, twenty-one studies reported the prognosis COVID-19 in patients with T2DM, ten studies reported the prognosis of COVID-19 in patients with sarcopenia, five studies discussed the outcomes of sarcopenia in patients with COVID-19, and one study reported sarcopenia outcomes in the presence of T2DM and COVID-19. CONCLUSION There is an obvious multidimensional relationship between T2DM, COVID-19 and sarcopenia which can cause prejudicial effects, poor prognosis, prolonged hospitalisation, lowered quality of life and a higher mortality rate during the current COVID-19 pandemic.
Collapse
Affiliation(s)
- Anmar Al-Taie
- Clinical Pharmacy Department, Faculty of Pharmacy, Istinye University, Istanbul, Turkey
| | - Oritsetimeyin Arueyingho
- EPSRC Centre for Doctoral Training in Digital Health and Care, University of Bristol, Bristol, UK
| | - Jalal Khoshnaw
- Pharmacy Department, Faculty of Pharmacy, Girne American University, Mersin, Turkey
| | - Abdul Hafeez
- Department of Pharmaceutics, Glocal School of Pharmacy, Glocal University, Saharanpur, Uttar Pradesh, India
| |
Collapse
|
3
|
Miyazaki S, Tamaki A, Wakabayashi H, Arai H. Definition, diagnosis, and treatment of respiratory sarcopenia. Curr Opin Clin Nutr Metab Care 2024; 27:210-218. [PMID: 38126204 DOI: 10.1097/mco.0000000000001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW Skeletal muscle weakness and wasting also occurs in the respiratory muscles, called respiratory sarcopenia. Respiratory sarcopenia may lead to worse clinical indicators and outcomes. We present a novel definition and diagnostic criteria for respiratory sarcopenia, summarize recent reports on the association between respiratory sarcopenia, physical and nutritional status, and clinical outcomes, and provide suggestions for the prevention and treatment of respiratory sarcopenia. RECENT FINDINGS Recently, a novel definition and diagnostic criteria for respiratory sarcopenia have been prepared. Respiratory sarcopenia is defined as a condition in which there is both low respiratory muscle strength and low respiratory muscle mass. Respiratory muscle strength, respiratory muscle mass, and appendicular skeletal muscle mass are used to diagnose respiratory sarcopenia. Currently, it is challenging to definitively diagnose respiratory sarcopenia due to the difficulty in accurately determining low respiratory muscle mass. Decreased respiratory muscle strength and respiratory muscle mass are associated with lower physical and nutritional status and poorer clinical outcomes. Exercise interventions, especially respiratory muscle training, nutritional interventions, and their combinations may effectively treat respiratory sarcopenia. Preventive interventions for respiratory sarcopenia are unclear. SUMMARY The novel definition and diagnostic criteria will contribute to promoting the assessment and intervention of respiratory sarcopenia.
Collapse
Affiliation(s)
| | - Akira Tamaki
- Department of Physical Therapy, School of Rehabilitation, Hyogo Medical University, Kobe
| | - Hidetaka Wakabayashi
- Department of Rehabilitation Medicine, Tokyo Women's Medical University Hospital, Tokyo
| | - Hidenori Arai
- National Center for Geriatrics and Gerontology, Obu, Japan
| |
Collapse
|
4
|
Seo H, Cha SI, Park J, Lim JK, Lee WK, Park JE, Choi SH, Lee YH, Yoo SS, Lee SY, Lee J, Kim CH, Park JY. Pectoralis Muscle Area as a Predictor of Mortality in Patients Hospitalized with Bronchiectasis Exacerbation. Respiration 2024; 103:257-267. [PMID: 38499001 DOI: 10.1159/000538091] [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: 08/08/2023] [Accepted: 02/27/2024] [Indexed: 03/20/2024] Open
Abstract
INTRODUCTION Data on factors related to mortality in patients with bronchiectasis exacerbation are insufficient. Computed tomography (CT) can measure the pectoralis muscle area (PMA) and is a useful tool to diagnose sarcopenia. This study aimed to evaluate whether PMA can predict mortality in patients with bronchiectasis exacerbation. METHODS Patients hospitalized due to bronchiectasis exacerbation at a single center were retrospectively divided into survivors and non-survivors based on 1-year mortality. Thereafter, a comparison of the clinical and radiologic characteristics was conducted between the two groups. RESULTS A total of 66 (14%) patients died at 1 year. In the multivariate analysis, age, BMI <18.4 kg/m2, sex-specific PMA quartile, ≥3 exacerbations in the previous year, serum albumin <3.5 g/dL, cystic bronchiectasis, tuberculosis-destroyed lung, and diabetes mellitus were independent predictors for the 1-year mortality in patients hospitalized with bronchiectasis exacerbation. A lower PMA was associated with a lower overall survival rate in the survival analysis according to sex-specific quartiles of PMA. PMA had the highest area under the curve during assessment of prognostic performance in predicting the 1-year mortality. The lowest sex-specific PMA quartile group exhibited higher disease severity than the highest quartile group. CONCLUSIONS CT-derived PMA was an independent predictor of 1-year mortality in patients hospitalized with bronchiectasis exacerbation. Patients with lower PMA exhibited higher disease severity. These findings suggest that PMA might be a useful marker for providing additional information regarding prognosis of patients with bronchiectasis exacerbation.
Collapse
Affiliation(s)
- Hyewon Seo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Seung-Ick Cha
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jongmin Park
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jae-Kwang Lim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Won Kee Lee
- Biostatistics, Medical Research Collaboration Center, Kyungpook National University, Daegu, Republic of Korea
| | - Ji-Eun Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Sun Ha Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yong Hoon Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Seung-Soo Yoo
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Shin-Yup Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Chang-Ho Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jae-Yong Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| |
Collapse
|
5
|
Knoedler S, Schliermann R, Knoedler L, Wu M, Hansen FJ, Matar DY, Obed D, Vervoort D, Haug V, Hundeshagen G, Paik A, Kauke-Navarro M, Kneser U, Pomahac B, Orgill DP, Panayi AC. Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis. Int J Surg 2023; 109:4238-4262. [PMID: 37696253 PMCID: PMC10720826 DOI: 10.1097/js9.0000000000000688] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 08/04/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties. METHODS The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design. RESULTS A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001). CONCLUSION Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.
Collapse
Affiliation(s)
- Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Rainer Schliermann
- Faculty of Social and Health Care Sciences, University of Applied Sciences Regensburg, Regensburg
| | - Leonard Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Mengfan Wu
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, People’s Republic of China
| | - Frederik J. Hansen
- Department of General and Visceral Surgery, Friedrich-Alexander University Erlangen, Erlangen
| | - Dany Y. Matar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Doha Obed
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Angie Paik
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Dennis P. Orgill
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Adriana C. Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| |
Collapse
|
6
|
Isaka T, Ito H, Yokose T, Saito H, Narimatsu H, Adachi H, Miura J, Murakami K, Kikunishi N, Shigeta N, Rino Y. Long-term changes in psoas muscle mass after lobectomy and segmentectomy for early-stage lung cancer. J Cachexia Sarcopenia Muscle 2023; 14:2540-2549. [PMID: 37740651 PMCID: PMC10751413 DOI: 10.1002/jcsm.13328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 05/12/2023] [Accepted: 08/21/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Segmentectomy is considered a less invasive procedure than lobectomy for patients with non-small cell lung cancer (NSCLC); however, little is known about the physiological mechanism underlying the lower invasiveness of segmentectomy. This study is aimed to compare the differences in the long-term changes in the psoas muscle mass after segmentectomy and lobectomy in patients with NSCLC. METHODS Overall 315 recurrence-free patients who underwent segmentectomy (n = 93) or lobectomy (n = 222) for clinical stage 0-I NSCLC between January 2016 and December 2018 and underwent computed tomography during the entire period of 6 months ≤ postoperative year (POY) 0.5 < 12 months, 12 months ≤ POY 1 < 24 months, 24 months ≤ POY 2 < 36 months, and 36 months ≤ POY 3 < 48 months were included. Bilateral psoas muscle area (PMA) at the L3 level was measured using each cross-sectional computed tomography scan. Differences between the segmentectomy and lobectomy groups in the mean change of postoperative PMA from the preoperative period were analysed using Student's t-test and mixed analysis of variance. Multivariable analysis was performed to identify the risk factors for PMA loss on POY 3 using logistic regression analysis. RESULTS The lobectomy group had a significantly larger PMA change than the segmentectomy group during each postoperative period (P < 0.001). Mixed analysis of variance revealed that the mean PMA change was significantly smaller in the segmentectomy group than in the lobectomy group during the observation period (P < 0.001). The mean change in the PMA was significantly larger from POY1 (-2.5%) to POY2 (-3.9%) and POY3 (-4.7%) in the lobectomy group (P = 0.003 and P < 0.001). However, PMA remained unchanged during the postoperative observation period in the segmentectomy group. In the multivariable analysis, the risk factors for PMA change ≤-3.3% (cut-off: mean change of PMA) at POY3 included lobectomy [odds ratio (OR), 3.32; 95% confidence interval (CI), 1.90-5.82; P < 0.001], male sex (OR, 1.92; 95% CI, 1.02-3.62; P = 0.044) and open thoracotomy (OR, 1.84; 95% CI, 1.11-3.05; P = 0.017). After propensity score matching, the mean change in PMA was smaller in the segmentectomy group (n = 75) than in the lobectomy group (n = 75) during the postoperative observation period (P < 0.001). CONCLUSIONS Psoas muscle mass was better maintained during the postoperative period by segmentectomy than by lobectomy. Psoas muscle mass reduction progressed over a long postoperative period after lobectomy. Segmentectomy via complete video-assisted thoracic surgery is associated with a lower likelihood of sarcopenia progression.
Collapse
Affiliation(s)
- Tetsuya Isaka
- Department of Thoracic SurgeryKanagawa Cancer CenterYokohamaJapan
- Department of SurgeryYokohama City UniversityYokohamaJapan
| | - Hiroyuki Ito
- Department of Thoracic SurgeryKanagawa Cancer CenterYokohamaJapan
| | | | - Haruhiro Saito
- Department of Thoracic OncologyKanagawa Cancer CenterYokohamaJapan
| | - Hiroto Narimatsu
- Department of Genetic MedicineKanagawa Cancer CenterYokohamaJapan
- Cancer Prevention and Cancer Control DivisionKanagawa Cancer Center Research InstituteYokohamaJapan
- Graduate School of Health InnovationKanagawa University of Human ServicesKawasakiJapan
| | - Hiroyuki Adachi
- Department of Thoracic SurgeryKanagawa Cancer CenterYokohamaJapan
| | - Jun Miura
- Department of Thoracic SurgeryKanagawa Cancer CenterYokohamaJapan
| | - Kotaro Murakami
- Department of Thoracic SurgeryKanagawa Cancer CenterYokohamaJapan
| | | | - Naoko Shigeta
- Department of Thoracic SurgeryKanagawa Cancer CenterYokohamaJapan
| | - Yasushi Rino
- Department of SurgeryYokohama City UniversityYokohamaJapan
| |
Collapse
|
7
|
Morikawa H, Oba T, Kiyosawa N, Iji R, Amitani M, Chino T, Shimizu T, Ono M, Ito T, Kanai T, Maeno K, Ito KI. Significance of skeletal muscle index-to-body mass index ratio as a predictor of post-surgical bleeding after mastectomy in patients with breast cancer. Breast Cancer 2023; 30:933-942. [PMID: 37440158 DOI: 10.1007/s12282-023-01483-0] [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: 04/25/2023] [Accepted: 07/06/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Post-surgical bleeding is a major complication of mastectomy in patients with breast cancer. However, the risk factors for post-surgical bleeding have not been well studied. Although obesity or reduced skeletal muscle mass is an indicator of cancer surgery complications, its impact on post-surgical bleeding after mastectomy remains unknown. METHODS In total, 563 patients with breast cancer who underwent mastectomy were included in this study. We evaluated the preoperative body mass index (BMI), skeletal muscle index (SMI), and SMI-to-BMI ratio and analyzed the association between these values and the incidence of post-surgical bleeding. RESULTS Post-surgical bleeding occurred in 33 (5.6%) patients. Mean BMI was significantly higher in the bleeding group (26.3 ± 4.7) than in the no-bleeding group (23.0 ± 4.1) (p < 0.001), whereas mean SMI was lower in the former group (45.0 ± 8.5) than in the latter group (48.0 ± 8.5) (p = 0.08). The bleeding group had significantly lower SMI-to-BMI ratio (1.71 ± 0.16) than the no-bleeding group (2.10 ± 0.23) (p < 0.001). Among these three parameters, SMI-to-BMI ratio had the highest area under the curve value in their receiver operating characteristic curves (0.73 for BMI, 0.59 for SMI, 0.92 for SMI-to-BMI ratio). Furthermore, on multivariate analysis, SMI-to-BMI ratio was an independent risk factor for post-surgical bleeding (hazard ratio, 38.4; 95% confidence interval, 13.9-136.2; p < 0.001). CONCLUSIONS SMI-to-BMI ratio is a superior predictive factor of post-surgical bleeding after mastectomy to either BMI or SMI alone.
Collapse
Affiliation(s)
- Hiroki Morikawa
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Takaaki Oba
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan.
| | - Nami Kiyosawa
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Ryoko Iji
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Masatsugu Amitani
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Tatsunori Chino
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Tadafumi Shimizu
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Mayu Ono
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Tokiko Ito
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Toshiharu Kanai
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Kazuma Maeno
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Ken-Ichi Ito
- Division of Breast and Endocrine Surgery, Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| |
Collapse
|
8
|
Shimoda M, Tanaka Y, Morimoto K, Nomura S, Yoshimori K, Ohta K. Comparison of the thickness of the erector spinae muscles between aspiration pneumonia and bacterial pneumonia patients. Aging Clin Exp Res 2023; 35:2657-2665. [PMID: 37676430 DOI: 10.1007/s40520-023-02542-4] [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: 01/20/2023] [Accepted: 08/20/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND AND AIMS Aspiration pneumonia is generally associated with deterioration of skeletal muscle mass, which is usually evaluated by the erector spinae muscle cross-sectional area (ESMCSA); however, no report has assessed ESMCSA in patients with aspiration pneumonia. Furthermore, erector spinae muscle thickness (ESMT) was developed to be easier to measure than ESMCSA. Therefore, this study investigated the relationship between ESMT and ESMCSA in aspiration pneumonia patients compared to bacterial pneumonia patients. METHODS We retrospectively collected data for 164 patients with aspiration pneumonia and 480 patients with bacterial pneumonia who were hospitalized at Fukujuji Hospital between September 2018 and May 2022. We assessed the correlations between ESMCSA and ESMT and compared the data between the two groups. RESULTS ESMT had a strong, proportional relationship with ESMCSA in all patients (r = 0.908, p < 0.001) and those with aspiration pneumonia (r = 0.896, p < 0.001). ESMCSA (median 671.8 mm2 [range 164.0-1636.7] vs. median 1057.0 mm2 [range 161.3-2412.5], p < 0.001) and ESMT (median 17.1 mm [range 6.95-34.4] vs. median 23.8 mm [range 6.95-43.7], p < 0.001) were significantly lower in patients with aspiration pneumonia. A multivariate analysis of aspiration pneumonia diagnosis showed significant independent differences from bacterial pneumonia in ESMCSA (odds ratio 0.998 [95% CI: 0.996-0.999], p = 0.001) and ESMT (odds ratio 0.90 [95% CI: 0.84-0.96], p = 0.002). CONCLUSION This study demonstrates a strong correlation between ESMCSA and ESMT. ESMT can be more easily used to evaluate skeletal muscle mass and can help in diagnosing aspiration pneumonia.
Collapse
Affiliation(s)
- Masafumi Shimoda
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), 3-1-24 Mastuyama, Kiyose City, Tokyo, 204-8522, Japan.
| | - Yoshiaki Tanaka
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), 3-1-24 Mastuyama, Kiyose City, Tokyo, 204-8522, Japan
| | - Kozo Morimoto
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), 3-1-24 Mastuyama, Kiyose City, Tokyo, 204-8522, Japan
| | - Sakika Nomura
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), 3-1-24 Mastuyama, Kiyose City, Tokyo, 204-8522, Japan
| | - Kozo Yoshimori
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), 3-1-24 Mastuyama, Kiyose City, Tokyo, 204-8522, Japan
| | - Ken Ohta
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), 3-1-24 Mastuyama, Kiyose City, Tokyo, 204-8522, Japan
| |
Collapse
|
9
|
Shimoda M, Yoshiyama T, Tanaka Y, Morimoto K, Okumura M, Kodama T, Nakajima K, Yoshimori K, Ohta K. Relationship between the thickness of erector spinae muscles and mortality in patients with pulmonary tuberculosis. Respir Investig 2023; 61:511-519. [PMID: 37267852 DOI: 10.1016/j.resinv.2023.04.011] [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: 12/15/2022] [Revised: 03/23/2023] [Accepted: 04/03/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Skeletal muscle mass is a known predictor of mortality in older patients. However, its relationship with tuberculosis is unclear. Skeletal muscle mass is determined by the cross-sectional area of erector spinae muscle (ESMCSA). Additionally, the erector spinae muscle thickness (ESMT) is an easier measurement than ESMCSA. This study investigated the relationship of ESMT and ESMCSA with mortality in tuberculosis patients. METHODS We retrospectively collected the data of 267 older patients (age ≥65 years) who were hospitalized due to tuberculosis at the Fukujuji Hospital from January 2019 to July 2021. This included 40 patients with 60-day mortality (the death group) and 227 patients with 60-day survival (the alive group). Here, we assessed the correlations between ESMCSA and ESMT, and the data were compared between the two groups. RESULTS ESMT had a strong proportional relationship with ESMCSA (r = 0.991, p < 0.001). ESMCSA (median 670.2 mm2 [interquartile range (IQR): 585.1-760.9] vs. 914.3 mm2 [717.6-1141.6], p < 0.001) and ESMT (median 16.7 mm [15.4-18.6] vs. 21.1 mm [18.0-25.5], p < 0.001) were significantly lower in the patients in the death group than those of patients in the alive group. A multivariable Cox proportional hazard model for 60-day mortality showed significantly independent differences in ESMT (hazard ratio [HR] 0.870 [95% confidence interval (Cl): 0.795-0.952], p = 0.003) and ESMCSA (HR 0.998 [95% Cl: 0.996-0.999], p = 0.009). CONCLUSIONS This study demonstrated a strong correlation between ESMCSA and ESMT, which were risk factors for mortality in patients with tuberculosis. Therefore, using ESMT is easier to predict mortality than ESMCSA.
Collapse
Affiliation(s)
- Masafumi Shimoda
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose City, Tokyo, Japan.
| | - Takashi Yoshiyama
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose City, Tokyo, Japan
| | - Yoshiaki Tanaka
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose City, Tokyo, Japan
| | - Kozo Morimoto
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose City, Tokyo, Japan
| | - Masao Okumura
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose City, Tokyo, Japan
| | - Tatsuya Kodama
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose City, Tokyo, Japan
| | - Kei Nakajima
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose City, Tokyo, Japan
| | - Kozo Yoshimori
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose City, Tokyo, Japan
| | - Ken Ohta
- Respiratory Disease Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Kiyose City, Tokyo, Japan
| |
Collapse
|
10
|
Matsuguma H, Hasumi K, Wakamatsu I, Nakahara R. Preoperative diagnosis of sarcopenia and postoperative outcome in patients with non-small-cell lung cancer. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6984717. [PMID: 36629471 DOI: 10.1093/ejcts/ezad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/09/2023] [Indexed: 01/12/2023]
Affiliation(s)
| | - Kenta Hasumi
- Division of Thoracic Surgery, Tochigi Cancer Center, Utsunomiya, Japan
| | - Ikuma Wakamatsu
- Division of Thoracic Surgery, Tochigi Cancer Center, Utsunomiya, Japan
| | - Rie Nakahara
- Division of Thoracic Surgery, Tochigi Cancer Center, Utsunomiya, Japan
| |
Collapse
|
11
|
Ueda D, Tsutani Y, Kamigaichi A, Kawamoto N, Tsubokawa N, Ito M, Mimae T, Miyata Y, Okada M. Impact of the amount of preoperative erector spinae muscle in stage I non-small-cell lung cancer. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6782957. [PMID: 36315076 DOI: 10.1093/ejcts/ezac510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/19/2022] [Accepted: 10/28/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Erector spinae muscle (ESM) is an antigravity muscle group that can be evaluated as an index of muscle loss on chest computed tomography. The amount of ESM has been reported to be related to the prognosis of several respiratory diseases. However, few studies clarify the impact on postoperative non-small-cell lung cancer (NSCLC). We investigated the relationship between ESM and postoperative prognosis in patients with early-stage NSCLC. METHODS We reviewed the medical records of 534 patients with stage I NSCLC who underwent lobectomy or segmentectomy. The ESM was identified by preoperative computed tomography, and the amount was normalized according to height and sex. Overall survival, lung cancer-related deaths and non-lung cancer-related deaths (NLCRD) were analysed using log-rank and Gray's tests. Multivariable analyses were conducted to identify factors that influenced overall survival (OS) and NLCRD. RESULTS The amount of ESM normalized according to height and sex was significantly associated with age and body mass index. When the amount was low, OS (5-year OS, 79.6 vs 89.5%; P< 0.001) and NLCRD (5-year cumulative mortality rate, 14.7 vs 6.8%; P< 0.001) were significantly worse, although no difference was found in lung cancer-related deaths. CONCLUSIONS The amount of preoperative ESM was strongly related to non-lung cancer-related death and was a significant prognostic factor for stage I NSCLC. Patients with a low amount of the muscle should be treated based on proper risk assessment.
Collapse
Affiliation(s)
- Daisuke Ueda
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yasuhiro Tsutani
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Atsushi Kamigaichi
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Nobutaka Kawamoto
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Norifumi Tsubokawa
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Masaoki Ito
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Takahiro Mimae
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshihiro Miyata
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Morihito Okada
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| |
Collapse
|
12
|
Ying-Hao P, Hai-Dong Z, Yuan F, Yong-Kang L, Sen L, Wei-Long X, Yu-Shan Y, Jun-Feng Z, Hai-Qi Z, Hua J. Correlation of CT-derived pectoralis muscle status and COVID-19 induced lung injury in elderly patients. BMC Med Imaging 2022; 22:144. [PMID: 35962312 PMCID: PMC9372984 DOI: 10.1186/s12880-022-00872-9] [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: 03/04/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To explore the association between CT-derived pectoralis muscle index (PMI) and COVID-19 induced lung injury. METHODS We enrolled 116 elderly COVID-19 patients linked to the COVID-19 outbreak in Nanjing Lukou international airport. We extracted three sessions of their CT data, including one upon admission (T1), one during the first 2 weeks when lung injury peaked (T2) and one on day 14 ± 2 (T3). Lung injury was assessed by CT severity score (CTSS) and pulmonary opacity score (POS). Pneumonia evolution was evaluated by changes of CT scores at T2 from T1(Δ). RESULTS The maximum CT scores in low PMI patients were higher than those of normal PMI patients, including CTSS1 (7, IQR 6-10 vs. 5, IQR 3-6, p < 0.001), CTSS2 (8, IQR 7-11 vs. 5, IQR 4-7, p < 0.001) and POS (2, IQR 1-2.5 vs. 1, IQR 1-2, p < 0.001). Comorbidity (OR = 6.15, p = 0.023) and the presence of low PMI (OR = 5.43, p = 0.001) were predictors of lung injury aggravation with ΔCTSS1 > 4. The presence of low PMI (OR = 5.98, p < 0.001) was the predictor of lung injury aggravation with ΔCTSS2 > 4. Meanwhile, presence of low PMI (OR = 2.82, p = 0.042) and incrementally increasing D-dimer (OR = 0.088, p = 0.024) were predictors of lung injury aggravation with ΔPOS = 2. CONCLUSIONS PMI can be easily assessed on chest CT images and can potentially be used as one of the markers to predict the severity of lung injury in elderly COVID-19 patients.
Collapse
Affiliation(s)
- Pei Ying-Hao
- Department of Intensive Care Unit, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Zhang Hai-Dong
- Department of Intensive Care Unit, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Fang Yuan
- Department of Geriatrics, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Liu Yong-Kang
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Liang Sen
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Xu Wei-Long
- Department of Endocrinology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Yang Yu-Shan
- First School of Clinical Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Zhu Jun-Feng
- First School of Clinical Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Zhou Hai-Qi
- Department of Intensive Care Unit, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China.
| | - Jiang Hua
- Department of Intensive Care Unit, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China.
| |
Collapse
|
13
|
Commentary: Identifying sarcopenia-can the pectoralis do the heavy lifting? J Thorac Cardiovasc Surg 2022; 163:789-790. [PMID: 33454105 DOI: 10.1016/j.jtcvs.2020.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 11/21/2022]
|
14
|
Ali AM, Kunugi H. Screening for Sarcopenia (Physical Frailty) in the COVID-19 Era. Int J Endocrinol 2021; 2021:5563960. [PMID: 34113379 PMCID: PMC8152925 DOI: 10.1155/2021/5563960] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/22/2021] [Accepted: 04/30/2021] [Indexed: 01/08/2023] Open
Abstract
Although the numbers of aged populations have risen considerably in the last few decades, the current coronavirus disease 2019 (COVID-19) has revealed an extensive vulnerability among these populations. Sarcopenia is an age-related disorder that increases hospitalization, dependencies, and mortality in older adults. It starts to develop in midlife or even earlier as a result of unbalanced diet/poor nutrition and low levels of physical activity, in addition to chronic disorders such as obesity and diabetes mellitus. Given that social isolation is adopted as the most protective measure against COVID-19, the level of physical activity and the intake of adequate diet have considerably declined, especially among older adults-denoting an increased possibility for developing sarcopenia. Research also shows a higher vulnerability of sarcopenic people to COVID-19 as well as the development of wasting disorders such as sarcopenia and cachexia in a considerable proportion of symptomatic and recovering COVID-19 patients. Muscular wasting in COVID-19 is associated with poor prognosis. Accordingly, early detection and proper management of sarcopenia and wasting conditions in older adults and COVID-19 patients may minimize morbidity and mortality during the current COVID-19 crisis. This review explored different aspects of screening for sarcopenia, stressing their relevance to the detection of altered muscular structure and performance in patients with COVID-19. Current guidelines recommend prior evaluation of muscle strength by simple measures such as grip strength to identify individuals with proven weakness who then would be screened for muscle mass loss. The latter is best measured by MRI and CT. However, due to the high cost and radiation risk entailed by these techniques, other simpler and cheaper techniques such as DXA and ultrasound are given preference. Muscle loss in COVID-19 patients was measured during the acute phase by CT scanning of the pectoralis muscle simultaneously during a routine check for lung fibrosis, which seems to be an efficient evaluation of sarcopenia among those patients with no additional cost. In recovering patients, muscle strength and physical performance have been evaluated by electromyography and traditional tests such as the six-minute walk test. Effective preventive and therapeutic interventions are necessary in order to prevent muscle loss and associated physical decline in COVID-19 patients.
Collapse
Affiliation(s)
- Amira Mohammed Ali
- Department of Behavioral Medicine, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo 187-8553, Japan
- Department of Psychiatric Nursing and Mental Health, Faculty of Nursing, Alexandria University, Alexandria, Egypt
| | - Hiroshi Kunugi
- Department of Psychiatry, Teikyo University School of Medicine, Tokyo, Japan
- Department of Mental Disorder Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
| |
Collapse
|
15
|
Burt BM. Commentary: Respiratory frailty: Sarcopenia in earnest. J Thorac Cardiovasc Surg 2020; 163:788. [PMID: 33309087 DOI: 10.1016/j.jtcvs.2020.10.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Bryan M Burt
- Division of General Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
| |
Collapse
|