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Horakova L, Kriemler S, Študent V, Pichler Hefti J, Hillebrandt D, Jean D, Mateikaitė-Pipirienė K, Paal P, Rosier A, Andjelkovic M, Beidlemann B, Derstine M, Keyes LE. Hormonal Contraception and Menstrual Cycle Control at High Altitude: A Scoping Review-UIAA Medical Commission Recommendations. High Alt Med Biol 2024. [PMID: 38607652 DOI: 10.1089/ham.2024.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024] Open
Abstract
Horakova, Lenka , Susi Kriemler, Vladimír Študent, Jacqueline Pichler Hefti, David Hillebrandt, Dominique Jean, Kastė Mateikaitė-Pipirienė, Peter Paal, Alison Rosier, Marija Andjelkovic, Beth Beidlemann, Mia Derstine, and Linda E. Keyes. Hormonal contraception and menstrual cycle control at high altitude: a scoping review-UIAA Medical Commission recommendations. High Alt Med Biol. 00:00-00, 2024. Background: Women who use hormonal contraception (HC) may have questions about their use during travel to high altitude. This scoping review summarizes current evidence on the efficacy and safety of HC and cycle control during high-altitude travel. Methods: We performed a scoping review for the International Climbing and Mountaineering Federation (UIAA) Medical Commission series on Women's Health in the Mountains. Pertinent literature from PubMed and Cochrane was identified by keyword search combinations (including contraception) with additional publications found by hand search. Results: We identified 17 studies from 7,165 potentially eligible articles. No articles assessed the efficacy of contraception during a short-term high-altitude sojourn. Current data show no advantage or disadvantage in HC users for acclimatization or acute mountain sickness (AMS). Use of HC during high-altitude travel is common and safe for menses suppression. A potential concern of estrogen-containing HC is the increased thrombotic risk, which theoretically could be compounded in hypobaric hypoxia. Conclusions: Evidence is limited for the interaction of HC and high altitude on performance, thrombosis, and contraceptive efficacy. HC does not affect the risk of AMS. The most efficacious and safest method at high altitude is generally the one women are most familiar with and already using.
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Affiliation(s)
- Lenka Horakova
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University Prague, Kladno, Czech Republic
| | - Susi Kriemler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Vladimír Študent
- Department of Gynecology and Obstetrics, Prachatice Hospital, Prachatice, Czech Republic
| | | | - David Hillebrandt
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- General Medical Practitioner, Holsorthy, United Kingdom
| | - Dominique Jean
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Pediatrics, Infectious Diseases and Altitude Medicine, Grenoble, France
| | - Kastė Mateikaitė-Pipirienė
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Diaverum Dialysis Clinic, Elektrėnai, Lithuania
| | - Peter Paal
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Alison Rosier
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
| | - Marija Andjelkovic
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Pharmacy, Singidunum University, Belgrade, Serbia
| | - Beth Beidlemann
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Mia Derstine
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado, USA
| | - Linda E Keyes
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado, USA
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Nair V, Singh S, Ashraf MZ, Yanamandra U, Sharma V, Prabhakar A, Ahmad R, Chatterjee T, Behera V, Guleria V, Patrikar S, Gupta S, Vishnoi MG, Rigvardhan, Kalshetty K, Sharma P, Bajaj N, Khaling TD, Wankhede TS, Bhattachar S, Datta R, Ganguli LP. Epidemiology and pathophysiology of vascular thrombosis in acclimatized lowlanders at high altitude: A prospective longitudinal study. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2022; 3:100016. [PMID: 37384264 PMCID: PMC10306047 DOI: 10.1016/j.lansea.2022.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Previous literature suggests that thrombosis is more common in lowlanders sojourning at high altitude (HA) compared to near-sea-level. Though the pathophysiology is partly understood, little is known of its epidemiology. To elucidate this, an observational prospective longitudinal study was conducted in healthy soldiers sojourning for months at HA. METHODS A total of 960 healthy male subjects were screened in the plains, of which 750 ascended, to altitudes above 15,000ft (4,472m). Clinical examination, haemogram, coagulogram, markers of inflammation and endothelial dysfunction, were studied at three time points during ascent and descent. The diagnosis of thrombosis was confirmed radiologically in all cases where a thrombotic event was suspected clinically. Subjects developing thrombosis at HA were labelled as Index Cases (ICs) and compared to a nested cohort of the healthy subjects (comparison group,(CG)) matched for altitude of stay. FINDINGS Twelve and three subjects, developed venous (incidence: 5,926/105 person-years) and arterial (incidence: 1,482/105 person-years) thrombosis at HA, respectively. The ICs had enhanced coagulation (FVIIa: p<0.001; FXa: p<0.001) and decreased levels of natural anticoagulants (thrombomodulin, p=0.016; tissue factor pathway inhibitor [TFPI]: p<0.001) and a trend to dampened fibrinolysis (tissue plasminogen activator tPA; p=0.078) compared to CG. ICs also exhibited statistically significant increase in the levels of endothelial dysfunction and inflammation markers (vascular cell adhesion molecule-1[VCAM-1], intercellular adhesion molecule-1 [ICAM-1], vascular endothelial growth factor receptor 3 [VEGFR-3], P-Selectin, CD40 ligand, soluble C-reactive protein and myeloperoxidase: p<0.001). INTERPRETATION The incidence of thrombosis in healthy subjects at HA was higher than that reported in literature at near sea-level. This was associated with inflammation, endothelial dysfunction, a prothrombotic state and dampened fibrinolysis. FUNDING Research grants from the Armed Forces Medical Research Committee, Office of the Director General of Armed Forces Medical Services (DGAFMS) & Defence Research and Development Organization (DRDO), Ministry of Defence, India.
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Affiliation(s)
- Velu Nair
- Department of the Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
- Director General Medical Services (Army), India
- Comprehensive Blood & Cancer Center (CBCC), Gandhinagar, Gujarat, India
| | - Surinderpal Singh
- Department of Physiology, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Physiology, Army College of Medical Sciences, New Delhi, India
| | - Mohammad Zahid Ashraf
- Defense Institute of Physiology & Allied Science (DIPAS), New Delhi, India
- Department of Biotechnology, Jamia Millia Islamia, New Delhi, India
| | - Uday Yanamandra
- Department of the Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
- 153 General Hospital, Leh, India
| | - Vivek Sharma
- Department of Imaging & Radiodiagnosis, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Radiology, Bharati Vidyapeeth Hospital & Medical College, Pune, Maharashtra, India
| | - Amit Prabhakar
- Defense Institute of Physiology & Allied Science (DIPAS), New Delhi, India
- Cardiovascular Research Institute (CVRI), University of California, San Francisco, USA
| | - Rehan Ahmad
- Department of Clinical Haematology and Centre for Stem Cell Therapy and Research, Army Hospital (Research and Referral), New Delhi, India
- Luchkee Health Pvt Ltd Vasant Kunj, New Delhi, India
| | - Tathagata Chatterjee
- Department of Laboratory Sciences and Molecular Medicine, Army Hospital (Research & Referral), New Delhi, India
- Department of Haematology and Stem Cell Transplant, ESIC Med College and Hospital, Faridabad, Haryana, India
| | - Vineet Behera
- Department of the Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Internal Medicine, INHS Asvini, Colaba, Mumbai, India
| | - Vivek Guleria
- Department of the Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Cardiology, Army Hospital (Research & Referral), New Delhi, India
| | - Seema Patrikar
- Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
| | - Shivi Gupta
- 403 Field Hospital, C/o 56 APO, India
- Indian Field Hospital, UN Mission, Malakal 71111, South Sudan
| | - Madan Gopal Vishnoi
- 403 Field Hospital, C/o 56 APO, India
- Department of Nuclear Medicine, Command Hospital (Eastern Command), Kolkata, India
| | - Rigvardhan
- Defense Institute of Physiology & Allied Science (DIPAS), New Delhi, India
| | - Kiran Kalshetty
- Regimental Medical Officer, 20 Grenadiers c/o 56 APO, India
- Department of Anaesthesiology, 305 Field Hospital, C/o 99 APO, India
| | - Prafull Sharma
- Department of the Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Cardiology, Military Hospital, Jalandhar, Punjab, India
| | - Nitin Bajaj
- Department of Internal Medicine, Command Hospital (Western Command), Chandimandir, Haryana, India
- Department of Cardiology, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Thyelnai D. Khaling
- Department of Physiology, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Physiology, Institute of Aerospace Medicine, Bangalore, Karnataka, India
| | - Tanaji Sitaram Wankhede
- Department of Physiology, Armed Forces Medical College, Pune, Maharashtra, India
- Department of Sports Medicine, Armed Forces Medical College, Pune, Maharashtra, India
| | - Srinivasa Bhattachar
- Department of Physiology, Institute of Aerospace Medicine, Bangalore, Karnataka, India
- High Altitude Medical Research Centre, Leh, Ladakh, India
| | - Rajat Datta
- Department of Cardiology, Army Hospital (Research & Referral), New Delhi, India
- Director General Armed Forces Medical Services, New Delhi, India
| | - Late Prosenjit Ganguli
- Department of Clinical Haematology and Centre for Stem Cell Therapy and Research, Army Hospital (Research and Referral), New Delhi, India
- Department of Pathology, Command Hospital (Eastern Command), Kolkata, India
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Treml B, Wallner B, Blank C, Fries D, Schobersberger W. The Influence of Environmental Hypoxia on Hemostasis—A Systematic Review. Front Cardiovasc Med 2022; 9:813550. [PMID: 35252392 PMCID: PMC8894865 DOI: 10.3389/fcvm.2022.813550] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Humans have been ascending to high altitudes for centuries, with a growing number of professional- and leisure-related sojourns occurring in this millennium. A multitude of scientific reports on hemostatic disorders at high altitude suggest that hypoxia is an independent risk factor. However, no systematic analysis of the influence of environmental hypoxia on coagulation, fibrinolysis and platelet function has been performed. To fill this gap, we performed a systematic literature review, including only the data of healthy persons obtained during altitude exposure (<60 days). The results were stratified by the degree of hypoxia and sub-categorized into active and passive ascents and sojourns. Twenty-one studies including 501 participants were included in the final analysis. Since only one study provided relevant data, no conclusions regarding moderate altitudes (1,500–2,500 m) could be drawn. At high altitude (2,500–5,400 m), only small pathophysiological changes were seen, with a possible impact of increasing exercise loads. Elevated thrombin generation seems to be balanced by decreased platelet activation. Viscoelastic methods do not support increased thrombogenicity, with fibrinolysis being unaffected by high altitude. At extreme altitude (5,400–8,850 m), the limited data showed activation of coagulation in parallel with stimulation of fibrinolysis. Furthermore, multiple confounding variables at altitude, like training status, exercise load, fluid status and mental stress, prevent definitive conclusions being drawn on the impact of hypoxia on hemostasis. Thus, we cannot support the hypothesis that hypoxia triggers hypercoagulability and increases the risk of thromboembolic disorders, at least in healthy sojourners.
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Affiliation(s)
- Benedikt Treml
- General and Surgical Intensive Care Medicine, Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Bernd Wallner
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
- *Correspondence: Bernd Wallner
| | - Cornelia Blank
- Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology UMIT, Hall i.T. and Tirol Kliniken GmbH, University Hospital Innsbruck, Innsbruck, Austria
| | - Dietmar Fries
- General and Surgical Intensive Care Medicine, Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Wolfgang Schobersberger
- Institute for Sports Medicine, Alpine Medicine and Health Tourism, Private University for Health Sciences, Medical Informatics and Technology UMIT, Hall i.T. and Tirol Kliniken GmbH, University Hospital Innsbruck, Innsbruck, Austria
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Trunk AD, Rondina MT, Kaplan DA. Venous Thromboembolism at High Altitude: Our Approach to Patients at Risk. High Alt Med Biol 2019; 20:331-336. [PMID: 31479310 DOI: 10.1089/ham.2019.0049] [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: 12/31/2022] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a prevalent disorder that confers substantial cardiovascular morbidity and, in serious cases, death. VTE has a complex and incompletely understood etiopathogenesis with genetic, acquired, and environmental risk factors. As the focus of this review, one environmental risk factor, which may interact with other risk factors such as hereditary and/or acquired thrombophilias, is travel to high altitude (HA), although current evidence is limited. As guidelines do not directly address this topic, we will discuss the epidemiology of HA-VTE, review the putative mechanisms for thrombosis at HA, and discuss our clinical approach to both risk stratification and counseling, including specific pharmacologic and nonpharmacologic recommendations for patients with elevated VTE risk before they travel to HA.
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Affiliation(s)
- Andrew D Trunk
- Department of Internal Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Matthew T Rondina
- Department of Internal Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah.,Department of Internal Medicine and GRECC, George E. Wahlen VAMC, Salt Lake City, Utah.,Department of Pathology, University of Utah Health Sciences Center, Salt Lake City, Utah.,Molecular Medicine Program, Eccles Institute of Human Genetics, University of Utah, Salt Lake City, Utah
| | - David A Kaplan
- Department of Internal Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
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Tyson JJ, Bjerke BP, Genuario JW, Noonan TJ. Thromboembolic Events After Arthroscopic Knee Surgery: Increased Risk at High Elevation. Arthroscopy 2016; 32:2350-2354. [PMID: 27318777 DOI: 10.1016/j.arthro.2016.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 04/04/2016] [Accepted: 04/05/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the incidence of thromboembolic events in patients undergoing arthroscopic surgery of the knee in centers located at elevations near sea level and compare those rates with the patients undergoing the same operations in centers at high elevation. METHODS A retrospective review was conducted using a database of a major health care system with surgery centers located throughout the United States. More than 115 centers located in 15 different states were analyzed for any reported thromboembolic events including deep vein thromboses and pulmonary embolism (PE) in patients who had undergone knee arthroscopy over a 2-year period. The centers located at elevations lower than 1,000 ft were considered sea level centers. Centers located at elevations above 4,000 ft were considered high-elevation centers. Centers located between 1,000 ft and 4,000 ft elevation were excluded. RESULTS A total of 35,877 patients underwent a knee arthroscopy at a low-elevation center and 10,181 patients underwent a knee arthroscopy at a high-elevation center between 2011 and 2012. During that same time period, 45 total venous thromboembolic events (VTEs) including 12 PEs occurred at centers considered low elevation, whereas 50 VTEs including 4 PEs occurred at centers considered high elevation. The incidence of VTE at low-elevation centers was 0.13%. The incidence of VTE at high-elevation centers was 0.49%. The difference was statistically significant, P < .0001. The relative risk of developing a VTE was 3.8 times higher at high elevation. There was no difference in PE incidence between high- and low-elevation centers (0.04% vs 0.03%, respectively; P = .78). CONCLUSIONS Patients undergoing arthroscopic procedures of the knee in centers at high elevation are at 3.8 times higher risk of developing a VTE than those undergoing the same procedures in centers at low elevations. There was no observed increased risk of PE. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Jared J Tyson
- Steadman-Hawkins Clinic-Denver, Greenwood Village, Colorado, U.S.A..
| | - Brian P Bjerke
- Steadman-Hawkins Clinic-Denver, Greenwood Village, Colorado, U.S.A
| | - James W Genuario
- Steadman-Hawkins Clinic-Denver, Greenwood Village, Colorado, U.S.A
| | - Thomas J Noonan
- Steadman-Hawkins Clinic-Denver, Greenwood Village, Colorado, U.S.A
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Hull CM, Rajendran D, Fernandez Barnes A. Deep Vein Thrombosis and Pulmonary Embolism in a Mountain Guide: Awareness, Diagnostic Challenges, and Management Considerations at Altitude. Wilderness Environ Med 2015; 27:100-6. [PMID: 26723546 DOI: 10.1016/j.wem.2015.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 10/07/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
Abstract
High intensity exercise is associated with several potentially thrombogenic risk factors, including dehydration and hemoconcentration, vascular trauma, musculoskeletal injuries, inflammation, long-distance travel, and contraceptive usage. These are well documented in case reports of venous thrombosis in track and field athletes. For mountaineers and those working at high altitude, additional risks exist. However, despite there being a high degree of vigilance for "classic" conditions encountered at altitude (eg, acute mountain sickness, high altitude pulmonary edema, and high altitude cerebral edema), mainstream awareness regarding thrombotic conditions and their complications in mountain athletes is relatively low. This is significant because thromboembolic events (including deep vein thrombosis, pulmonary embolism, and cerebral vascular thrombosis) are not uncommon at altitude. We describe a case of deep vein thrombosis and pulmonary embolism in a male mountain guide and discuss the diagnostic issues encountered by his medical practitioners. Potential risk factors affecting blood circulation (eg, seated car travel and compression of popliteal vein) and blood hypercoagulability (eg, hypoxia, environmental and psychological stressors [avalanche risk, extreme cold]) relevant to the subject of this report and mountain athletes in general are identified. Considerations for mitigating and managing thrombosis in addition to personalized care planning at altitude are discussed. The prevalence of thrombosis in mountain athletes is uncharted, but lowlanders increasingly go to high altitude to trek, ski, or climb. Blood clots can and do occur in physically active people, and thrombosis prevention and recognition will demand heightened awareness among participants, healthcare practitioners, and the altitude sport/leisure industry at large.
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Affiliation(s)
- Claire M Hull
- Swansea University Medical School, Singleton Park, Swansea, Wales, United Kingdom (Dr Hull).
| | - Dévan Rajendran
- the European School of Osteopathy, Research Department, Boxley House, Kent, United Kingdom (Dr Rajendran)
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7
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DeLoughery TG. Anticoagulation Considerations for Travel to High Altitude. High Alt Med Biol 2015; 16:181-5. [DOI: 10.1089/ham.2015.0058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Thomas G. DeLoughery
- Division of Hematology/Medical Oncology, Department of Medicine, and Division of Laboratory Medicine, Department of Pathology, Oregon Health Sciences University, Portland, Oregon
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Vanella L, Li M, Kim D, Malfa G, Bellner L, Kawakami T, Abraham NG. ApoA1: mimetic peptide reverses adipocyte dysfunction in vivo and in vitro via an increase in heme oxygenase (HO-1) and Wnt10b. Cell Cycle 2012; 11:706-14. [PMID: 22306989 DOI: 10.4161/cc.11.4.19125] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Insulin resistance is a risk factor in the development of type 2 diabetes and is a major cause of atherosclerosis. Reduction in heme oxygenase (HO-1) has been shown to exacerbate vascular dysfunction and insulin resistance in obese mice and involves a decrease in adiponectin levels. Adiponectin is released from mesenchymal stem cell (MSC)-derived adipocytes, its levels are decreased in type 2 diabetes. We hypothesized that the apoA1 mimetic peptide, L-4F, will target the expression of the HO-1-adiponectin axis and reverse adipocyte dysfunction both in vivo and in vitro. The administration of L-4F [2 mg/Kg/daily (i.p.) for 4-week to 8-week-old obese (ob) mice restored adipocyte function, increased adiponectin release (p < 0.05) and decreased the levels of IL-1 and IL-6 (p < 0.05)]. These perturbations were associated with an increase in insulin sensitivity (p < 0.01 vs. untreated ob mice) and decreased glucose levels (309 + 42 vs. 201 + 8 mg/d after L-4F treatment). Treatment of both mesenchymal stem cell (MSC)-derived adipocytes with L-4F (50 μg/ml) increased adiponectin (p < 0.05), decreased IL-1 and IL-6 (p < 0.05) levels and increased MSC-derived adipocyte cell numbers by 50% in S phase (p < 0.05). MSC-derived adipocytes treated with L-4F increased WNT10b and decreased Peg 1/Mest. Inhibition of HO activity reversed the decrease in the adipogenic response gene, Peg 1/Mest. An increase of HO-1 expression by L-4F increased insulin-receptor phosphorylation. These findings support the hypothesis that L-4F increases early adipocyte markers, HO-1-adiponectin, WNT10b and decreases Peg1/Mest, negative regulators of adipocyte differentiation.
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Affiliation(s)
- Luca Vanella
- Department of Physiology & Pharmacology, University of Toledo College of Medicine, Toledo, OH, USA
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