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Yeo BSY, Chan JH, Tan BKJ, Liu X, Tay L, Teo NWY, Charn TC. Olfactory Impairment and Frailty: A Systematic Review and Meta-Analysis. JAMA Otolaryngol Head Neck Surg 2024:2821102. [PMID: 38990553 PMCID: PMC11240234 DOI: 10.1001/jamaoto.2024.1854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
Importance Olfactory impairment (OI) and frailty are prevalent conditions associated with aging, but studies investigating their association with each other have been discordant. Objective To summarize current evidence surrounding the association between OI and frailty. Data Sources PubMed, Embase, Cochrane Library, SCOPUS, and CINAHL from inception to November 28, 2023. Study Selection This study included observational studies investigating the association between objectively or subjectively assessed OI and objectively evaluated frailty among adults. Data Extraction and Synthesis Two independent authors extracted data into a structured template. Maximally adjusted estimates were pooled using a random-effects model, and statistical heterogeneity was evaluated using I2 values. Additional prespecified subgroup and sensitivity analyses were performed. This study used the Newcastle-Ottawa Scale for bias assessment and the Grading of Recommendations Assessment, Development and Evaluation framework for overall evidence quality evaluation. Main Outcomes and Measures The primary outcome was the cross-sectional association between OI and frailty, for which the odds of frailty were compared between participants with and without OI. The secondary outcome was the cross-sectional association between frailty and OI, for which the odds of OI were compared between participants with and without frailty. Results This study included 10 studies with 10 624 patients (52.9% female; mean [SD] age, 62.9 [9.6] years). The Newcastle-Ottawa Scale score of studies ranged from low to moderate. Grading of Recommendations Assessment, Development and Evaluation scores ranged from low to moderate. OI was associated with a 2.32-fold (odds ratio [OR], 2.32; 95% CI, 1.63-3.31; I2 = 0%) greater odds of frailty compared with individuals with healthy olfactory function. The odds of OI was progressively greater with categorical frailty status, with a 1.55-fold (OR, 1.55; 95% CI, 1.32-1.82; I2 = 0%), 2.28-fold (OR, 2.28; 95% CI, 1.96-2.65; I2 = 0%), and 4.67-fold (OR, 4.67; 95% CI, 2.77-7.86; I2 = 0%) increase in odds for individuals with prefrailty, frailty, and the most frailty, respectively, compared with robust individuals. The results demonstrated stability in subgroup analyses (geographical continent of study, objective vs subjective olfactory assessment) and sensitivity tests. Conclusions and Relevance The results of this systematic review and meta-analysis suggest that there is an association between OI and frailty, with an increase in the odds of OI with worsening categorical frailty status among individuals with prefrailty, frailty, and the most frailty. OI may be a potential biomarker for frailty. Future studies could delve into whether OI may be a modifiable risk factor for frailty.
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Affiliation(s)
- Brian Sheng Yep Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jun He Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Xuandao Liu
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Laura Tay
- Department of General Medicine, Sengkang General Hospital, Singapore
- SingHealth Duke-NUS Centre of Memory and Cognitive Disorders, Singapore
| | - Neville Wei Yang Teo
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore
- Surgery Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Tze Choong Charn
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore
- Surgery Academic Clinical Programme, Duke-NUS Medical School, Singapore
- Department of Otolaryngology-Head and Neck Surgery, Sengkang General Hospital, Singapore
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Cheng MZ, Vohra V, Wang H, Katuri A, Langdon JM, Xue QL, Rowan NR. The association between olfactory subdomains and frailty: A prospective case‒control study investigation. Int Forum Allergy Rhinol 2024. [PMID: 38940232 DOI: 10.1002/alr.23398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/03/2024] [Accepted: 06/13/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Amidst the rise of frailty among a globally aging population, olfactory decline has emerged as a harbinger of frailty and mortality in population-level studies. However, the relationships between frailty and the olfactory subdomains of identification (OI), discrimination (OD), and threshold (OT) remain unexplored. This study prospectively examined the association between olfactory subdomains and the physical frailty phenotype (PFP) to investigate olfactory evaluation as a means of frailty screening. METHODS A case‒control study of 45 frail and 45 non-frail individuals matched by age and sex. OT, OD, OI (range 0‒16), and composite sum (threshold, discrimination, and identification scores [TDI], range 0‒48) were measured with Sniffin' Sticks. PFP was defined by presence of three or more criteria: physical inactivity, self-reported exhaustion, muscle weakness, slow gait, and unintentional weight loss. Conditional logistic regression evaluated associations between olfactory subdomains and frailty. RESULTS Ninety individuals with mean age of 83.1 ± 4.9 years, 60% female (n = 54), and 87.8% white (n = 79) were included. Olfactory scores were significantly lower in the frail group for OI (9.2 vs. 12.1, p < 0.001), OD (8.1 vs. 11.6, p < 0.001), OT (4.4 vs. 8.5, p < 0.001), and TDI (21.7 vs. 32.2, p < 0.001) than in the non-frail group. A single-point decrease in olfactory score was associated with increased odds of frailty in OT (odds ratio [OR]: 2.21, 95% confidence interval: [1.22, 3.98]), OD (OR: 2.19, 95% CI: [1.32, 3.65]), OI (OR: 2.29, 95% CI: [1.19, 4.39]), and TDI (OR: 1.54, 95% CI: [1.14, 2.08]). CONCLUSION The robust association between olfactory subdomain scores and frailty suggests that olfaction may be an accessible signifier of frailty. Future studies should investigate this relationship longitudinally to assess predictive relationships.
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Affiliation(s)
- Michael Z Cheng
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Varun Vohra
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hang Wang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Akhil Katuri
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jacqueline M Langdon
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Qian-Li Xue
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Chamberlin KW, Yuan Y, Li C, Luo Z, Reeves M, Kucharska‐Newton A, Pinto JM, Ma J, Simonsick EM, Chen H. Olfactory Impairment and the Risk of Major Adverse Cardiovascular Outcomes in Older Adults. J Am Heart Assoc 2024; 13:e033320. [PMID: 38847146 PMCID: PMC11255730 DOI: 10.1161/jaha.123.033320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/27/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Olfactory impairment is common in older adults and may be associated with adverse cardiovascular health; however, empirical evidence is sparse. We examined olfaction in relation to the risk of coronary heart disease (CHD), stroke, and congestive heart failure (CHF). METHODS AND RESULTS This study included 2537 older adults (aged 75.6±2.8 years) from the Health ABC (Health, Aging, and Body Composition) study with olfaction assessed by the 12-item Brief Smell Identification Test in 1999 to 2000, defined as poor (score ≤8), moderate (9-10), or good (11-12). The outcomes were incident CHD, stroke, and CHF. During up to a 12-year follow-up, 353 incident CHD, 258 stroke, and 477 CHF events were identified. Olfaction was statistically significantly associated with incident CHF, but not with CHD or stroke. After adjusting for demographics, risk factors, and biomarkers of CHF, the cause-specific hazard ratio (HR) of CHF was 1.32 (95% CI, 1.05-1.66) for moderate and 1.28 (95% CI, 1.01-1.64) for poor olfaction. These associations were robust in preplanned subgroup analyses by age, sex, race, and prevalent CHD/stroke. While the subgroup results were not statistically significantly different, the association of olfaction with CHF appeared to be evident among participants who reported very good to excellent health (HR, 1.47 [95% CI, 1.01-2.14] for moderate; and 1.76 [95% CI, 1.20-2.58] for poor olfaction), but not among those with fair to poor self-reported health (HR, 1.04 [95% CI, 0.64-1.70] for moderate; and 0.92 [95% CI, 0.58-1.47] for poor olfaction). CONCLUSIONS In community-dwelling older adults, a single olfaction test was associated with a long-term risk for incident CHF, particularly among those reporting very good to excellent health.
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Affiliation(s)
- Keran W. Chamberlin
- Department of Epidemiology and Biostatistics, College of Human MedicineMichigan State UniversityEast LansingMI
| | - Yaqun Yuan
- Department of Epidemiology and Biostatistics, College of Human MedicineMichigan State UniversityEast LansingMI
| | - Chenxi Li
- Department of Epidemiology and Biostatistics, College of Human MedicineMichigan State UniversityEast LansingMI
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human MedicineMichigan State UniversityEast LansingMI
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, College of Human MedicineMichigan State UniversityEast LansingMI
| | - Anna Kucharska‐Newton
- Department of EpidemiologyGillings School of Global Public Health, University of North Carolina at Chapel HillChapel HillNC
| | - Jayant M. Pinto
- Section of Otolaryngology‐Head and Neck Surgery, Department of SurgeryThe University of Chicago Medicine and Biological SciencesChicagoIL
| | - Jiantao Ma
- Division of Nutrition Epidemiology and Data Science, Gerald J. and Dorothy R. Friedman School of Nutrition Science and PolicyTufts UniversityBostonMA
| | - Eleanor M. Simonsick
- Translational Gerontology Branch, Intramural Research Program of the National Institutes of HealthNational Institute on AgingBethesdaMD
| | - Honglei Chen
- Department of Epidemiology and Biostatistics, College of Human MedicineMichigan State UniversityEast LansingMI
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Kamath V, Chen H, Shrestha S, Mechanic-Hamilton D, Deal JA, Mosley TH, Schneider ALC. Normative Data for the 12-Item Sniffin' Sticks Odor Identification Test in Older Adults. Arch Clin Neuropsychol 2024; 39:335-346. [PMID: 37883325 PMCID: PMC11042920 DOI: 10.1093/arclin/acad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVE Quantitative olfactory assessment has demonstrated clinical utility for the evaluation of a range of neurologic, psychiatric, and sinonasal conditions. Here, we provide age, sex, race, and education-specific normative data for the 12-item Sniffin Sticks Odor Identification Test (SSOIT-12) in older Black and White U.S. adults without preclinical or clinical dementia or sinonasal disease. METHOD A sample of 2,224 Atherosclerosis Risk in Communities study participants aged 66-89 years were included. A normative regression equation was developed using a linear model for the association of age, sex, race, and education with odor identification score. Regression-based normative mean scores and percentiles were generated by age, sex, race, and education groups. RESULTS Participants (mean age = 74 years, 59% women, 20% Black, 48% > high school education) had a mean SSOIT-12 score of 9.8. Age, sex, race, and education were all associated with odor identification performance (all ps < .05). A linear regression model for the predicted SSOIT-12 score was developed for use with an individual's actual SSOIT-12 score in order to calculate the Z-score and corresponding percentile for a specific age, sex, race, and education group. Data are also reported in tabular format. CONCLUSIONS Our study provides SSOIT-12 normative data obtained from a large population of White and Black older adults without preclinical or clinical dementia or sinonasal disease living in the USA. These findings can aid clinicians in assessing the degree of olfactory loss, establishing concordance with a person's perception of olfactory difficulties and quantitatively monitoring changes in olfactory performance over time.
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Affiliation(s)
- Vidyulata Kamath
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Honglei Chen
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI 48824, USA
| | - Srishti Shrestha
- The Memory Impairment and Neurodegenerative Dementia (MIND) Center, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Dawn Mechanic-Hamilton
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Jennifer A Deal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21287, USA
- Cochlear Center for Hearing and Public Health, Baltimore, MD 21287, USA
| | - Thomas H Mosley
- The Memory Impairment and Neurodegenerative Dementia (MIND) Center, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Andrea L C Schneider
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
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Yuan Y, Chamberlin KW, Li C, Luo Z, Simonsick EM, Kucharska-Newton A, Chen H. Olfaction and Mobility in Older Adults. JAMA Otolaryngol Head Neck Surg 2024; 150:201-208. [PMID: 38236595 PMCID: PMC10797520 DOI: 10.1001/jamaoto.2023.4375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 11/22/2023] [Indexed: 01/19/2024]
Abstract
Importance Decreased mobility is a hallmark of aging. Olfactory dysfunction is common in older adults and may be associated with declines in mobility. Objective To determine whether poor olfaction was associated with faster declines in mobility in older adults. Design, Setting, and Participants This cohort study included 2500 participants from the Health, Aging, and Body Composition Study. Participants completed the Brief Smell Identification Test during the year 3 clinical visit (1999-2000) and were followed for up to 7 years. A data analysis was conducted between January and July 2023. Exposures Olfaction was defined as good (test score, 11-12), moderate (9-10), hyposmia (7-8), or anosmia (0-6). Main Outcomes and Measures Mobility was measured using the 20-m usual and fast walking tests in clinical visit years 3 to 6, 8, and 10 and the 400-m fast walking test in years 4, 6, 8, and 10. Results The primary analyses included 2500 participants (1292 women [51.7%]; 1208 men [48.3%]; 960 Black [38.4%] and 1540 White [61.6%] individuals; mean [SD] age, 75.6 [2.8] years). Multivariate-adjusted analyses showed that poor olfaction was associated with slower walking speed at baseline and a faster decline over time. Taking the 20-m usual walking test as an example, compared with participants with good olfaction, the speed at baseline was 0.027 (95% CI, 0-0.053) m/s slower for those with hyposmia and 0.034 (95% CI, 0.005-0.062) m/s slower for those with anosmia. Longitudinally, the annual decline was 0.004 (95% CI, 0.002-0.007) m/s/year faster for those with hyposmia and 0.01 (95% CI, 0.007-0.013) m/s/year faster for those with anosmia. Similar results were obtained for the 20-m and 400-m fast walking tests. Further, compared with participants with good olfaction, the odds of being unable to do the 400-m test were 2.02 (95% CI, 1.17-3.48) times higher for those with anosmia at the year 8 visit and 2.73 (95% CI, 1.40-5.35) times higher at year 10. Multiple sensitivity and subgroup analyses supported the robustness and generalizability of the findings. Conclusion and Relevance The results of this cohort study suggest that poor olfaction is associated with a faster decline in mobility in older adults. Future studies should investigate underlying mechanisms and potential health implications.
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Affiliation(s)
- Yaqun Yuan
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Keran W. Chamberlin
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Chenxi Li
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Eleanor M. Simonsick
- Laboratory of Epidemiology and Population Science, Intramural Research Program of the National Institutes of Health, National Institute on Aging, Bethesda, Maryland
| | - Anna Kucharska-Newton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill
| | - Honglei Chen
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
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Cao Z, Yang A, White AJ, Purdy F, Li C, Luo Z, D’Aloisio AA, Suarez L, Deming-Halverson S, Pinto JM, Chen JC, Werder EJ, Kaufman JD, Sandler DP, Chen H. Ambient Air Pollutants and Olfaction among Women 50-79 Years of Age from the Sister Study. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:87012. [PMID: 37594315 PMCID: PMC10436839 DOI: 10.1289/ehp12066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Poor olfaction is common in older adults and may have profound adverse implications on their health. However, little is known about the potential environmental contributors to poor olfaction. OBJECTIVE We investigated ambient fine particulate matter [PM ≤ 2.5 μ m in aerodynamic diameter (PM 2.5 )] and nitrogen dioxide (NO 2 ) in relation to poor olfaction in middle-aged to older women. METHODS The Sister Study is a nationwide cohort of 50,884 women in the United States with annual average air pollutant exposures estimated based on participants' residences from enrollment (2003-2009) through 2017. This analysis was limited to 3,345 women, 50-79 years of age as of January 2018, who completed the Brief Smell Identification Test (B-SIT) in 2018-2019. Poor olfaction was defined as a B-SIT score of ≤ 9 in the primary analysis. We conducted multivariable logistic regressions, accounting for covariates and study sampling design. RESULTS Overall, we found little evidence for associations of air pollutants with poor olfaction. The odds ratio (OR) and 95% confidence interval (CI) of poor olfaction for each interquartile range (IQR) increment of air pollutants in 2006 were 1.03 (95% CI: 0.91, 1.17) for PM 2.5 (per 3.3 μ g / m 3 ) and 1.08 (95% CI: 0.96, 1.22) for NO 2 (per 5.7 ppb ). Results were similar in the analyses using the most recent (2017) or the cumulative average (2006-2017) air pollutant exposure data. Secondary analyses suggested potential association in certain subgroups. The OR per IQR was 1.35 (95% CI: 1.11, 1.65) for PM 2.5 among younger participants (< 54.2 years of age) and 1.87 (95% CI: 1.29, 2.71) for NO 2 among current smokers. DISCUSSION This study did not find convincing evidence that air pollutants have lasting detrimental effects on the sense of smell of women 50-79 years of age. The subgroup analyses are exploratory, and the findings need independent confirmation. https://doi.org/10.1289/EHP12066.
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Affiliation(s)
- Zichun Cao
- Department of Epidemiology and Biostatistics, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Aiwen Yang
- Department of Epidemiology and Biostatistics, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Alexandra J. White
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina, USA
| | - Frank Purdy
- Department of Epidemiology and Biostatistics, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Chenxi Li
- Department of Epidemiology and Biostatistics, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
| | - Aimee A. D’Aloisio
- Social & Scientific Systems, DLH Holdings Corporation, Durham, North Carolina, USA
| | - Lourdes Suarez
- Social & Scientific Systems, DLH Holdings Corporation, Durham, North Carolina, USA
| | | | - Jayant M. Pinto
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jiu-Chiuan Chen
- Department of Population and Public Health Sciences, University of Southern California (USC), Los Angeles, California, USA
- Department of Neurology, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Emily J. Werder
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina, USA
| | - Joel D. Kaufman
- Department of Environmental and Occupational Health Sciences, University of Washington School of Medicine (UW Medicine), Seattle, Washington, USA
- Department of Medicine, UW Medicine, Seattle, Washington, USA
- Department of Epidemiology, UW Medicine, Seattle, Washington, USA
| | - Dale P. Sandler
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina, USA
| | - Honglei Chen
- Department of Epidemiology and Biostatistics, Michigan State University College of Human Medicine, East Lansing, Michigan, USA
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Saraswathula A, Schlosser RJ, Rowan NR. Reimbursement for Olfactory Testing: A Growing Need at a Unique Time in History. JAMA Otolaryngol Head Neck Surg 2023; 149:567-568. [PMID: 37166819 DOI: 10.1001/jamaoto.2023.0837] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
This Viewpoint addresses the lack of reimbursement for olfactory testing, which is especially important in a time when the populations of older adults and patients with COVID-19–associated olfactory dysfunction have grown.
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Affiliation(s)
- Anirudh Saraswathula
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Nicholas R Rowan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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