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Ullah S, Qureshi AZ, Kedowah K, AlHargan A, Niaz A. Rehabilitation of a patient with spinal cord decompression sickness: First case report from Saudi Arabia. Clin Case Rep 2019; 7:2231-2234. [PMID: 31788285 PMCID: PMC6878043 DOI: 10.1002/ccr3.2453] [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: 05/09/2019] [Revised: 07/17/2019] [Accepted: 08/05/2019] [Indexed: 12/01/2022] Open
Abstract
This case brings attention to development of rehabilitation protocols for patients with decompression sickness (DCS). A lack of data regarding DCS renders the need of conducting multicenter studies to document the epidemiology and outcomes of spinal cord DCS in Saudi Arabia.
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Affiliation(s)
- Sami Ullah
- Department of Physical Medicine and RehabilitationKing Fahad Medical CityRiyadhSaudi Arabia
| | - Ahmad Zaheer Qureshi
- Department of Physical Medicine and RehabilitationKing Fahad Medical CityRiyadhSaudi Arabia
| | - Kholoud Kedowah
- Department of Physical Medicine and RehabilitationKing Abdullah Medical CityMeccaSaudi Arabia
| | - Afnan AlHargan
- Department of Physical Medicine and RehabilitationKing Fahad Medical CityRiyadhSaudi Arabia
| | - Asim Niaz
- Department of Physical Medicine and RehabilitationKing Fahad HospitalDammamSaudi Arabia
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Saadi A, Ferenczi EA, Reda H. Spinal Decompression Sickness in an Experienced Scuba Diver: A Case Report and Review of Literature. Neurohospitalist 2019; 9:235-238. [PMID: 31534615 DOI: 10.1177/1941874419828895] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Decompression sickness from diving is a rare but potentially reversible cause of spinal injury. Early treatment with hyperbaric oxygen is associated with a better neurologic outcome, making prompt recognition and management clinically important. We describe a case of a 65-year-old diver who presented with thoracic back pain and bilateral leg weakness after a 70 feet of sea water (fsw) (21 meters of sea water [msw]) dive, with no acute abnormality on spinal magnetic resonance imaging (MRI). He made a partial recovery after extended hyperbaric oxygen therapy. We discuss the epidemiology and pathophysiology of central nervous system injury in decompression sickness, as well as acute management and prognostic factors for recovery, including the role of adjunctive therapies and the implications of negative MRI. Ultimately, clinicians should make the diagnosis of spinal cord decompression sickness based primarily on clinical evaluation, not on MRI findings.
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Affiliation(s)
- Altaf Saadi
- Partners Neurology Residency Program, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, MA, USA
| | - Emily A Ferenczi
- Partners Neurology Residency Program, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, MA, USA
| | - Haatem Reda
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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Seyithanoğlu MH, Abdallah A, Dündar TT, Kitiş S, Aralaşmak A, Gündağ Papaker M, Sasani H. Investigation of Brain Impairment Using Diffusion-Weighted and Diffusion Tensor Magnetic Resonance Imaging in Experienced Healthy Divers. Med Sci Monit 2018; 24:8279-8289. [PMID: 30447152 PMCID: PMC6252049 DOI: 10.12659/msm.911475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The aim of this study was to understand the changes of decompression illness in healthy divers by comparing diffusion-weighted (DWI) and diffusion tensor MRI findings among healthy professional divers and healthy non-divers with no history of diving. Material/Methods A total of 26 people were recruited in this prospective study: 11 experienced divers with no history of neurological decompression disease (cohort) and 15 healthy non-divers (control). In all study subjects, we evaluated apparent diffusion coefficient (ADC) and type of diffusion tensor metric fractional anisotropy (FA) values of different brain locations (e.g., frontal and parieto-occipital white matter, hippocampus, globus pallidus, putamen, internal capsule, thalamus, cerebral peduncle, pons, cerebellum, and corpus callosum). Results ADC values of hippocampus were high in divers but low in the control group; FA values of globus pallidus and putamen were lower in divers compared to the control group. DWI depicted possible changes due to hypoxia in different regions of the brain. Statistically significant differences in ADC values were found in hypoxia, particularly in the hippocampus (p=0.0002), while FA values in the globus pallidus and putamen were statistically significant (p=0.015 and p=0.031, respectively). We detected forgetfulness in 6 divers and deterioration in fine-motor skills in 2 divers (p=0.002 and p=0.17, respectively). All of them were examined using neuro-psychometric tests. Conclusions Repeated hyperbaric exposure increases the risk of white matter damage in experienced healthy divers without neurological decompression illness. The hippocampus, globus pallidus, and putamen are the brain areas responsible for memory, learning, navigation, and fine-motor skills and are sensitive to repeated hyperbaric exposure.
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Affiliation(s)
| | - Anas Abdallah
- Department of Neurosurgery, Bezmialem Vakif University, Istanbul, Turkey
| | - Tolga Turan Dündar
- Department of Neurosurgery, Bezmialem Vakif University, Istanbul, Turkey
| | - Serkan Kitiş
- Department of Neurosurgery, Bezmialem Vakif University, Istanbul, Turkey
| | - Ayşe Aralaşmak
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Hadi Sasani
- Department of Radiology, Faculty of Medicine, Namik Kemal University, Tekirdag, Turkey
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Rao PJ, Phan K, Ball J. Acute hemorrhagic paraplegia in a thoracic spinal hemangioblastoma after free diving. JOURNAL OF SPINE SURGERY (HONG KONG) 2016; 2:69-71. [PMID: 27683699 PMCID: PMC5039839 DOI: 10.21037/jss.2016.01.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 12/30/2015] [Indexed: 06/06/2023]
Affiliation(s)
- Prashanth J. Rao
- Department of Neurosurgery, Royal North Shore Hospital (RNSH), Sydney, Australia
- University of New South Wales (UNSW), Sydney, Australia
| | - Kevin Phan
- University of New South Wales (UNSW), Sydney, Australia
| | - Jonathon Ball
- Department of Neurosurgery, Royal North Shore Hospital (RNSH), Sydney, Australia
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Kamtchum Tatuene J, Pignel R, Pollak P, Lovblad KO, Kleinschmidt A, Vargas MI. Neuroimaging of diving-related decompression illness: current knowledge and perspectives. AJNR Am J Neuroradiol 2014; 35:2039-44. [PMID: 24924550 DOI: 10.3174/ajnr.a4005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Diving-related decompression illness is classified into 2 main categories: arterial gas embolism and decompression sickness. The latter is further divided into types 1 and 2, depending on the clinical presentation. MR imaging is currently the most accurate neuroimaging technique available for the detection of brain and spinal cord lesions in neurologic type 2 decompression sickness. Rapid bubble formation in tissues and the bloodstream during ascent is the basic pathophysiologic mechanism in decompression illness. These bubbles can damage the central nervous system through different mechanisms, namely arterial occlusion, venous obstruction, or in situ toxicity. Neuroimaging studies of decompression sickness have reported findings associated with each of these mechanisms: some typical results are summarized and illustrated in this article. We also review the limitations of previous work and make practical methodologic suggestions for future neuroimaging studies.
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Affiliation(s)
- J Kamtchum Tatuene
- From the Neurology Division (J.K.T., P.P., A.K.), Department of Clinical Neurosciences
| | - R Pignel
- Hyperbaric Medicine Centre (R.P.), Department of Emergency Medicine
| | - P Pollak
- From the Neurology Division (J.K.T., P.P., A.K.), Department of Clinical Neurosciences
| | - K O Lovblad
- Neuroradiology Division (K.O.L., M.I.V.), Department of Imaging and Medical Information Sciences, Geneva University Hospitals, Geneva, Switzerland
| | - A Kleinschmidt
- From the Neurology Division (J.K.T., P.P., A.K.), Department of Clinical Neurosciences
| | - M I Vargas
- Neuroradiology Division (K.O.L., M.I.V.), Department of Imaging and Medical Information Sciences, Geneva University Hospitals, Geneva, Switzerland.
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Liu X, Cao Y, Gao G, Mao R, Bi L, Geng M. Gene expression profile of type II spinal cord decompression sickness. Spinal Cord 2014; 52:606-10. [PMID: 24796448 DOI: 10.1038/sc.2014.65] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 04/01/2014] [Indexed: 01/03/2023]
Abstract
STUDY DESIGN This study was an experimental, controlled, animal study. OBJECTIVE This study was to determine the changes of molecular pathology in spinal cord decompression sickness (SC-DCS) based on a rabbit model of SC-DCS with the aid of an all-gene expression profile chip. SETTING Qingdao, Shandong Province, China. METHODS A gene expression profile chip containing 43 803 genes was used to compare the gene expressions in the spinal cords of four male New Zealand white rabbits in the SC-DCS and control groups, respectively. Selected differentially expressed genes were identified with quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) and immunohistochemistry. RESULTS The chip hybridization results showed that the SC-DCS group had nine upregulated and seventeen downregulated genes, compared with the control group. These genes were mainly related to inflammation, ion channels, the cell cycle, material transfer and apoptosis. The qRT-PCR results showed that parathyroid hormone and tumor necrosis factor alpha (TNF-α) genes were upregulated compared with the control group (P<0.01). However, the acyl-CoA synthetase and voltage-gated channel genes were downregulated (P<0.05). The immunohistochemical staining results confirmed that there were significantly greater expression levels of TNF-α in the spinal cord tissues of the SC-DCS group compared with the control group. CONCLUSIONS The spinal cord lesions of SC-DCS involve multiple gene changes in the rabbit; however, the significance of these findings needs further research. Meanwhile, the gene expression profile chip results provide us with a better understanding of the pathogenesis of DCS.
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Affiliation(s)
- X Liu
- Department of Pathology, General Hospital of Jinan Military Command, Jinan, China
| | - Y Cao
- Department of Pathology, General Hospital of Jinan Military Command, Jinan, China
| | - G Gao
- Department of Hyperbaric Medicine, No. 401, Hospital of PLA, Qingdao, China
| | - R Mao
- Department of Pathology, General Hospital of Jinan Military Command, Jinan, China
| | - L Bi
- Department of Pathology, General Hospital of Jinan Military Command, Jinan, China
| | - M Geng
- Department of Pathology, General Hospital of Jinan Military Command, Jinan, China
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Abstract
Diving exposes a person to the combined effects of increased ambient pressure and immersion. The reduction in pressure when surfacing can precipitate decompression sickness (DCS), caused by bubble formation within tissues due to inert gas supersaturation. Arterial gas embolism (AGE) can also occur due to pulmonary barotrauma as a result of breath holding during ascent or gas trapping due to disease, causing lung hyperexpansion, rupture and direct entry of alveolar gas into the blood. Bubble disease due to either DCS or AGE is collectively known as decompression illness. Tissue and intravascular bubbles can induce a cascade of events resulting in CNS injury. Manifestations of decompression illness can vary in severity, from mild (paresthesias, joint pains, fatigue) to severe (vertigo, hearing loss, paraplegia, quadriplegia). Particularly as these conditions are uncommon, early recognition is essential to provide appropriate management, consisting of first aid oxygen, targeted fluid resuscitation and hyperbaric oxygen, which is the definitive treatment. Less common neurologic conditions that do not require hyperbaric oxygen include rupture of a labyrinthine window due to inadequate equalization of middle ear pressure during descent, which can precipitate vertigo and hearing loss. Sinus and middle ear overpressurization during ascent can compress the trigeminal and facial nerves respectively, causing temporary facial hypesthesia and lower motor neuron facial weakness. Some conditions preclude safe diving, such as seizure disorders, since a convulsion underwater is likely to be fatal. Preventive measures to reduce neurologic complications of diving include exclusion of individuals with specific medical conditions and safe diving procedures, particularly related to descent and ascent.
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Affiliation(s)
- E Wayne Massey
- Department of Neurology, Duke University Medical Center, Durham, NC, USA.
| | - Richard E Moon
- Departments of Anesthesiology and Medicine, Duke University Medical Center, Durham, NC, USA
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Havnes MB, Widerøe M, Thuen M, Torp SH, Brubakk AO, Møllerløkken A. Simulated dive in rats lead to acute changes in cerebral blood flow on MRI, but no cerebral injuries to grey or white matter. Eur J Appl Physiol 2013; 113:1405-14. [PMID: 23232710 PMCID: PMC3654193 DOI: 10.1007/s00421-012-2565-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/27/2012] [Indexed: 11/23/2022]
Abstract
In this study, the effect of a simulated dive on rat brain was investigated using several magnetic resonance imaging (MRI)-methods and immunohistochemistry. Rats were randomly assigned to a dive- or a control group. The dive group was exposed to a simulated air dive to 600 kPa for 45 min. Pulmonary artery was monitored for vascular gas bubbles by ultrasound. MRI was performed 1 h after decompression and at one and 2 weeks after the dive with a different combination of MRI sequences at each time point. Two weeks after decompression, rats were sacrificed and brains were prepared for histology. Dived rats had a different time-curve for the dynamic contrast-enhanced MRI signal than controls with higher relative signal intensity, a tendency towards longer time to peak and a larger area under the curve for the whole brain on the acute MRI scan. On MRI, 1 and 2 weeks after dive, T2-maps showed no signal abnormalities or morphological changes. However, region of interest based measurements of T2 showed higher T2 in the brain stem among decompressed animals than controls after one and 2 weeks. Microscopical examination including immunohistochemistry did not reveal apparent structural or cellular injuries in any part of the rat brains. These observations indicate that severe decompression does not seem to cause any structural or cellular injury to the brain tissue of the rat, but may cause circulatory changes in the brain perfusion in the acute phase.
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Affiliation(s)
- Marianne B Havnes
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, 7489 Trondheim, Norway.
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Hennedige T, Chow W, Ng YY, Chung-Tsing GC, Lim TCC, Kei PL. MRI in spinal cord decompression sickness. J Med Imaging Radiat Oncol 2012; 56:282-8. [PMID: 22697324 DOI: 10.1111/j.1754-9485.2012.02386.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Spinal cord decompression sickness (DCS) is a rare condition that can lead to spinal cord infarction. Despite the low incidence of diving-related DCS, we have managed to collect the data and MRI findings of seven patients who have been diagnosed with and treated for DCS in our local hyperbaric facility. This study describes the clinical presentation, MRI spinal cord findings, treatment administered and outcome of these patients. METHODS The patient medical records, from 1997 to 2007, were retrospectively reviewed. All patients with a final diagnosis of DCS and who underwent examination were included. The images were independently reviewed by two radiologists who recorded the location and number of lesions within the spinal cord. The Frankel grading was used to assess the initial and clinical outcome response. RESULTS Patchy-increased T2W changes affecting several levels at the same time were found. Contrary to the popular notion that venous infarction is the leading cause of DCS, most of our patients also demonstrated affliction of grey matter, which is typically seen in an arterial pattern of infarction. Initial involvement of multiple (>6) spinal cord levels was associated with a poor outcome. Patients who continued to have multiple neurological sequelae with less than 50% resolution of symptoms despite recompression treatment were also those who had onset of symptoms within 30 min of resurfacing. CONCLUSIONS DCS is probably a combination of both arterial and venous infarction. Short latency to the onset of neurological symptoms and multilevel cord involvement may be associated with a poorer outcome.
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Affiliation(s)
- Tiffany Hennedige
- Department of Diagnostic Radiology, Singapore General Hospital, National Neuroscience Institute, Singapore.
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Usvald D, Vodicka P, Hlucilova J, Prochazka R, Motlik J, Kuchorova K, Johe K, Marsala S, Scadeng M, Kakinohana O, Navarro R, Santa M, Hefferan MP, Yaksh TL, Marsala M. Analysis of Dosing Regimen and Reproducibility of Intraspinal Grafting of Human Spinal Stem Cells in Immunosuppressed Minipigs. Cell Transplant 2010; 19:1103-22. [DOI: 10.3727/096368910x503406] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In recent studies using a rat aortic balloon occlusion model, we have demonstrated that spinal grafting of rat or human neuronal precursors or human postmitotic hNT neurons leads to progressive amelioration of spasticity and rigidity and corresponding improvement in ambulatory function. In the present study, we characterized the optimal dosing regimen and safety profile of human spinal stem cells (HSSC) when grafted into the lumbar spinal cord segments of naive immunosuppressed minipigs. Gottingen-Minnesota minipigs (18–23 kg) were anesthetized with halothane, mounted into a spine-immobilization apparatus, and received five bilateral injections of HSSC delivered in 2, 4, 6, 8, or 10 μl of media targeted into L2-L5 central gray matter (lamina VII). The total number of delivered cells ranged between 2,500 and 100,000 per injection. Animals were immunosuppressed with Prograf® for the duration of study. After cell grafting, ambulatory function was monitored daily using a Tarlov's score. Sensory functions were assessed by mechanically evoked skin twitch test. Animals survived for 6–7 weeks. Three days before sacrifice animals received daily injections of bromodeoxyuridine (100 mg/kg; IV) and were then transcardially perfused with 4% paraformaldehyde. Th12-L6 spinal column was then dissected; the spinal cord was removed and scanned with MRI. Lumbar transverse spinal cord sections were then cut and stained with a combination of human-specific (hNUMA, hMOC, hNSE, hSYN) or nonspecific (DCX, MAP2, GABA, CHAT) antibodies. The total number of surviving cells was estimated using stereological quantification. During the first 12–24 h after cell grafting, a modest motor weakness was observed in three of eight animals but was no longer present at 4 days to 7 weeks. No sensory dysfunction was seen at any time point. Postmortem MRI scans revealed the presence of the individual grafts in the targeted spinal cord areas. Histological examination of spinal cord sections revealed the presence of hNUMA-immunoreactive grafted cells distributed between the base of the dorsal horn and the ventral horn. In all grafts intense hMOC, DCX, and hSYN immunoreactivity in grafted cells was seen. In addition, a rich axodendritic network of DCX-positive processes was identified extending 300–700 μm from the grafts. On average, 45% of hNUMA-positive neurons were GABA immunoreactive. Stereological analysis of hNUMA-positive cells showed an average of 2.5- to 3-fold increase in number of surviving cells compared with the number of injected cells. Analysis of spinal structural morphology showed that in animals injected with more than 50,000 cells/injection or volumes of injectate higher than 6 μl/injection there was tissue expansion and disruption of the local axodendritic network. Based on these data the safe total number of injected cells and volume of injectate were determined to be 30,000 cells delivered in ≤6 μl of media. These data demonstrate that highly reproducible delivery of a potential cell therapeutic candidate into spinal parenchyma can be achieved across a wide range of cell doses by direct intraspinal injections. The resulting grafts uniformly showed robust cell survival and progressive neuronal maturation.
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Affiliation(s)
- Dusan Usvald
- Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic
| | - Peter Vodicka
- Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic
| | - Jana Hlucilova
- Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic
| | - Radek Prochazka
- Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic
| | - Jan Motlik
- Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Libechov, Czech Republic
| | - Karolina Kuchorova
- Anesthesiology Research Laboratory, University of California, San Diego, La Jolla, CA, USA
- Institute of Neurobiology, Slovak Academy of Sciences, Kosice, Slovakia
| | - Karl Johe
- Neuralstem, Inc., Rockville, MD, USA
| | - Silvia Marsala
- Anesthesiology Research Laboratory, University of California, San Diego, La Jolla, CA, USA
| | - Miriam Scadeng
- UCSD Center for Functional MRI, University of California, San Diego, La Jolla, CA, USA
| | - Osamu Kakinohana
- Anesthesiology Research Laboratory, University of California, San Diego, La Jolla, CA, USA
| | - Roman Navarro
- Anesthesiology Research Laboratory, University of California, San Diego, La Jolla, CA, USA
| | - Marian Santa
- Faculty of Health, Department of Emergency Medicine, University of Presov, Presov, Slovakia
| | - Michael P. Hefferan
- Anesthesiology Research Laboratory, University of California, San Diego, La Jolla, CA, USA
| | - Tony L. Yaksh
- Anesthesiology Research Laboratory, University of California, San Diego, La Jolla, CA, USA
| | - Martin Marsala
- Anesthesiology Research Laboratory, University of California, San Diego, La Jolla, CA, USA
- Institute of Neurobiology, Slovak Academy of Sciences, Kosice, Slovakia
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