1
|
Fathi M, Mirjafari A, Yaghoobpoor S, Ghanikolahloo M, Sadeghi Z, Bahrami A, Myers L, Gholamrezanezhad A. Diagnostic utility of whole-body computed tomography/pan-scan in trauma: a systematic review and meta-analysis study. Emerg Radiol 2024; 31:251-268. [PMID: 38396199 PMCID: PMC10995012 DOI: 10.1007/s10140-024-02213-5] [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] [Received: 01/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
Trauma is a significant cause of mortality and morbidity. It is crucial to diagnose trauma patients quickly to provide effective treatment interventions in such conditions. Whole-body computed tomography (WBCT)/pan-scan is an imaging technique that enables a faster and more efficient diagnosis for polytrauma patients. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of WBCT in diagnosing injuries in polytrauma patients. We will also assess its impact on the mortality rate and length of hospital stay among trauma centers between patients who underwent WBCT and those who did not (non-WBCT). Twenty-seven studies meeting our inclusion criteria were selected among PubMed, Scopus, Web of Science, and Google Scholar. The criteria were centered on the significance of WBCT/pan-scan application in trauma patients. Stata version 15 was used to perform statistical analysis on the data. The authors have also used I2 statistics to evaluate heterogeneity. Egger and Begg's tests were performed to rule out any publication bias. Total of twenty-seven studies including 68,838 trauma patients with a mean age of 45.0 ± 24.7 years were selected. Motor vehicle collisions were the most common cause of blunt injuries (80.0%). Head, neck, and face injuries were diagnosed in 44% (95% CI, 0.28-0.60; I2 = 99.8%), 6% (95% CI, 0.02-0.09; I2 = 97.2%), and 9% (95% CI, 0.05-0.13; I2 = 97.1%), respectively. Chest injuries were diagnosed by WBCT in 39% (95% CI, 0.28-0.51; I2 = 99.8%), abdominal injuries in 23% (95% CI, 0.03-0.43; I2 = 99.9%) of cases, spinal injuries 19% (95% CI, 0.11-0.27; I2 = 99.4%), extremity injuries 33% (95% CI, 0.23-0.43; I2 = 99.2%), and pelvic injuries 11% (95% CI, 0.04-0.18; I2 = 97.4%). A mortality odd ratio of 0.94 (95% CI, 0.83-1.06; I2 = 40.1%) was calculated while comparing WBCT and non-WBCT groups. This systematic review and meta-analysis provide insight into the possible safety, efficacy, and efficiency of WBCT/pan-scan as a diagnostic tool for trauma patients with serious injuries, regardless of their hemodynamic status. In patients with serious injuries from trauma, whether or not there are indicators of hemodynamic instability, our recommended approach is to, wherever possible, perform a WBCT without stopping the hemostatic resuscitation. By using this technology, the optimal surgical strategy for these patients can be decided upon without causing any delays in their final care or greatly raising their radiation dose.
Collapse
Affiliation(s)
- Mobina Fathi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arshia Mirjafari
- Center for Minimally Invasive Therapeutics (C-MIT), University of California, Los Angeles, CA, USA
- Department of Bioengineering, University of California, Los Angeles, CA, USA
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA, USA
| | - Shirin Yaghoobpoor
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Zohre Sadeghi
- Department of Radiology, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Ashkan Bahrami
- Faculty of Medicine, Kashan University of Medical Science, Kashan, Iran
| | - Lee Myers
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, USA.
| |
Collapse
|
2
|
Gianola S, Bargeri S, Biffi A, Cimbanassi S, D’Angelo D, Coclite D, Facchinetti G, Fauci AJ, Ferrara C, Di Nitto M, Napoletano A, Punzo O, Ranzato K, Tratsevich A, Iannone P, Castellini G, Chiara O. Structured approach with primary and secondary survey for major trauma care: an overview of reviews. World J Emerg Surg 2023; 18:2. [PMID: 36600301 PMCID: PMC9814503 DOI: 10.1186/s13017-022-00472-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/25/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND A structured approach involves systematic management of trauma patients. We aim to conduct an overview of reviews about the clinical efficacy and safety of structured approach (i.e., primary and secondary survey) by guideline checklist compared to non-structured approach (i.e. clinical examination); moreover, routine screening whole-body computer tomography (WBCT) was compared to non-routine WBCT in patients with suspected major trauma. METHODS We systematically searched MEDLINE (PubMed), EMBASE and Cochrane Database of Systematic Reviews up to 3 May 2022. Systematic reviews (SRs) that investigated the use of a structured approach compared to a non-structured approach were eligible. Two authors independently extracted data, managed the overlapping of primary studies belonging to the included SRs and calculated the corrected covered area (CCA). The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS We included nine SRs investigating two comparisons in stable trauma patients: structured approach vs non-structured approach (n = 1) and routine WBCT vs non-routine WBCT (n = 8). The overlap of included primary studies was generally high across outcomes (CCA ranged between 20.85 and 42.86%) with some discrepancies in the directions of effects across reviews. The application of a structured approach by checklist may improve adherence to guidelines (e.g. Advanced Trauma Life Support) during resuscitation and might lead to a reduction in mortality among severely injured patients as compared to clinical examination (Adjusted OR 0.51; 95% CI 0.30-0.89; p = 0.018; low certainty of evidence). The use of routine WBCT seems to offer little to no effects in reducing mortality and time spent in emergency room or department, whereas non-routine WBCT seems to offer little to no effects in reducing radiation dose, intensive care unit length of stay (LOS) and hospital LOS (low-to-moderate certainty of evidence). CONCLUSIONS The application of structured approach by checklist during trauma resuscitation may improve patient- and process-related outcomes. Including non-routine WBCT seems to offer the best trade-offs between benefits and harm. Clinicians should consider these findings in the light of their clinical context, the volume of patients in their facilities, the need for time management, and costs.
Collapse
Affiliation(s)
- Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
| | - Silvia Bargeri
- grid.417776.4Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Annalisa Biffi
- grid.7563.70000 0001 2174 1754National Centre for Healthcare Research and Pharmacoepidemiology,, University of Milano-Bicocca, Milan, Italy ,grid.7563.70000 0001 2174 1754Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Stefania Cimbanassi
- grid.4708.b0000 0004 1757 2822General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Daniela D’Angelo
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Daniela Coclite
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Gabriella Facchinetti
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Alice Josephine Fauci
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Carla Ferrara
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Di Nitto
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Antonello Napoletano
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Ornella Punzo
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Katya Ranzato
- grid.420421.10000 0004 1784 7240Gruppo MultiMedica, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Alina Tratsevich
- grid.7563.70000 0001 2174 1754National Centre for Healthcare Research and Pharmacoepidemiology,, University of Milano-Bicocca, Milan, Italy ,grid.7563.70000 0001 2174 1754Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Primiano Iannone
- grid.416290.80000 0004 1759 7093Dipartimento di Medicina Interna, Azienda USL, Ospedale Maggiore, Largo Nigrisoli 2, 40133 Bologna, Italy
| | - Greta Castellini
- grid.417776.4Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Osvaldo Chiara
- grid.4708.b0000 0004 1757 2822General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | | |
Collapse
|
3
|
Iacobellis F, Brillantino A, Di Serafino M, Dell'Aversano Orabona G, Grassi R, Cappabianca S, Scaglione M, Romano L. Economic and clinical benefits of immediate total-body CT in the diagnostic approach to polytraumatized patients: a descriptive analysis through a literature review. Radiol Med 2022; 127:637-644. [PMID: 35553349 DOI: 10.1007/s11547-022-01495-4] [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: 02/04/2022] [Accepted: 04/14/2022] [Indexed: 11/30/2022]
Abstract
Major trauma is an event causing injuries that may determine an immediate or potential risk to the patient survival. A correct management of major trauma is decisive in reducing disability, which has relevance both from the point of view of the quality of life of the single individual and from the point of view of health expenditure. The primary clinical approach to the polytraumatized patients is managed, in most cases, as outlined in the guidelines of Advanced Trauma Life Support, proposing conventional radiological investigations, such as chest and pelvis x-ray, and of FAST (focused abdominal sonography in trauma)/E-FAST (extended FAST) examinations, followed by selective targeted computed tomography (CT). This approach is questionable and is increasingly common in clinical practice the adoption of the immediate total-body CT in the diagnostic approach to the hemodynamically stable polytraumatized patient. However, the potential advantages of such conduct both in terms of clinical benefits and in terms of cost-effectiveness still need to be discussed. The objective of this review article consists of a descriptive analysis of the economic and clinical benefits of the adoption of immediate total-body CT in polytrauma patients through a literature review.
Collapse
Affiliation(s)
- Francesca Iacobellis
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy.
| | - Antonio Brillantino
- Department of Emergency Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | | | - Roberto Grassi
- Department of Radiology, University of Campania "L. Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Salvatore Cappabianca
- Department of Radiology, University of Campania "L. Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Mariano Scaglione
- Department of Clinical and Experimental Medicine, University of Sassari, Via Roma 151, 07100, Sassari, Italy.,Department of Radiology, The James Cook University Hospital, Middlesbrough, TS4 3BW, UK.,School of Health and Life Sciences, Teesside University, Middlesbrough, TS1 3BX, UK
| | - Luigia Romano
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| |
Collapse
|
4
|
Maghraby NH, Alshaqaq HM, AlQattan AS, Alfaraj AF, Alghamdi OA, Alzawad MJ, Farcy DA. Negative Whole-Body Computed Tomography Scans in Polytrauma Patients: A Retrospective Cohort Study. Open Access Emerg Med 2020; 12:305-313. [PMID: 33122955 PMCID: PMC7591101 DOI: 10.2147/oaem.s263754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/18/2020] [Indexed: 11/24/2022] Open
Abstract
Background Whole-body computed tomography (WBCT) has been a mainstay and an integral part of the evaluation of polytrauma patients in trauma centers and emergency departments (ED) for a comprehensive evaluation of the extent of injuries. However, routine use of WBCT remains controversial since it exposes patients to radiation and exponentially increases financial expense. The primary objective was to determine the rate of negative WBCT in polytrauma patients. Patients and Methods A retrospective cohort study was conducted at an academic hospital in the Kingdom of Saudi Arabia, which is a dedicated trauma center with a mean of 237,392 ED visits and 10,714 trauma per year. The study included all adult (≥18 years) polytrauma patients who presented to our ED, requiring trauma team activation, and underwent WBCT as part of their evaluation from January 2016 to May 2017. We excluded pediatric patients, patients transferred from another facility, and pregnant patients. The primary endpoint was to measure the rate of negative WBCT in polytraumatized patients. Results A total of 186 patients were included with a mean age of 28.8 ± 12.9 years. The rate of negative WBCT scans was 20.4%. The positive scans were subclassified based on the number of anatomical body regions that were affected radiologically. One body region was affected in 47 patients (31.8%), two body regions were affected in 50 patients (33.8%), and ≥3 body regions were affected in 51 patients (34.3%). In a subset analysis, we identified that oxygen saturation <94% and GCS ≤8 were associated with positive CT scans. Conclusion Our study revealed a slightly higher rate of utilization of WBCT in the management of trauma patients compared to studies with similar practice. We believe that in the correct setting with incorporating high index of suspicion, a physical examination with attention to vital signs and mental status, performing E-FAST, and dedicated X-Rays is a way to potentially reduce the use of WBCT in polytrauma patients.
Collapse
Affiliation(s)
- Nisreen H Maghraby
- Department of Emergency Medicine, King Fahd University Hospital-College of Medicine, Imam Abdulrahman Bin Faisal University, AlKhobar, Kingdom of Saudi Arabia
| | - Hassan M Alshaqaq
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Abdullah Saleh AlQattan
- Department of General Surgery, King Fahad Specialist Hospital-Dammam, Kingdom of Saudi Arabia
| | - Adnan Fawzi Alfaraj
- Department of Emergency Medicine, King Fahad Specialist Hospital-Dammam, Kingdom of Saudi Arabia
| | - Omar A Alghamdi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Malak J Alzawad
- Department of Psychiatry, Ministry of Health, Dammam, Kingdom of Saudi Arabia
| | - David A Farcy
- Mount Sinai Medical Center, Department of Emergency Medicine, Miami Beach, Florida, USA
| |
Collapse
|
5
|
Arruzza E, Chau M, Dizon J. Systematic review and meta-analysis of whole-body computed tomography compared to conventional radiological procedures of trauma patients. Eur J Radiol 2020; 129:109099. [PMID: 32563164 DOI: 10.1016/j.ejrad.2020.109099] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE The superior diagnostic accuracy of CT makes it an attractive tool for initial trauma imaging. This meta-analysis aimed to assess the evidence regarding the value of whole-body CT (WBCT) as part of the primary survey, in comparison to conventional radiological procedures. METHODS A comprehensive systematic search of the literature was conducted using keywords applied in Scopus, Cochrane and PubMed databases. Articles were eligible if they contained original data comparing the use of WBCT in the primary survey, with conventional radiological procedures. Outcomes included overall and 24 -h mortality, emergency department (ED) time, intensive care unit (ICU) and hospital length of stay (LOS), and multiple organ dysfunction syndrome/failure (MODS/MOF) incidence. Radiation dose, mechanical ventilation duration and cost were evaluated qualitatively. Analysis was performed with Covidence, MedCalc Version 19.1.3. and Meta-Essentials. RESULTS Fourteen studies were included. Statistical pooling demonstrated comparable rates between conventional procedures and WBCT (OR = 0.854, CI = 0.715-1.021, p = 0.083) in 63,529 patients across 11 studies. A significant finding favouring WBCT was discovered for ED time (SMD = -0.709, CI -1.198 to -0.220, p = 0.004). Patients experienced similar 24 -h mortality rates (p = 0.450), MODS/MOF incidence (p = 0.274), and hospital (p = 0.541) and ICU LOS (p = 0.457). WBCT is associated with increased radiation dose and mechanical ventilation duration. CONCLUSION This review demonstrates that WBCT markedly reduces time spent in ED. No significant differences in mortality rate are suggested. WBCT currently entails greater radiation dose and mechanical ventilation time. Further research is necessitated to address limitations of predominately retrospective observational data available.
Collapse
Affiliation(s)
- Elio Arruzza
- University of South Australia, UniSA Allied Health & Human Performance, South Australia, 5000, Australia.
| | - Minh Chau
- University of South Australia, UniSA Allied Health & Human Performance, South Australia, 5000, Australia
| | - Janine Dizon
- University of South Australia, UniSA Allied Health & Human Performance, International Centre for Allied Health Evidence (iCAHE), South Australia, 5000, Australia
| |
Collapse
|
6
|
Whole body computed tomography in multi trauma patients: Review of the current literature. Turk J Emerg Med 2018; 18:142-147. [PMID: 30533556 PMCID: PMC6261098 DOI: 10.1016/j.tjem.2018.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 01/29/2023] Open
Abstract
Many authors adopt the Selected Computed Tomography (SCT) approach of the Advanced Trauma Life Support (ATLS) for the management of multiple trauma patients. In the SCT approach, the initial physical examination is followed by conventional radiography (cervical X-ray, chest X-ray, pelvic X-ray and Focused Abdominal Sonography in Trauma (FAST)), and the computed tomography (CT) of the specific body regions if indicated. An alternative to this traditional approach is the Whole-body Computed Tomography (WBCT) protocol, which became widespread all over the world in the last two decades to minimize the rate of missed injuries and decrease the mortality rate. According to the literature, the WBCT approach is superior to the traditional SCT approach in the time of imaging, diagnostic accuracy, and mortality rates. Conversely, WBCT increases the cancer risk due to additional irradiation. Therefore, it is recommended that the WBCT protocol should be reserved for only severe multi-trauma patients. However, further studies to define severe patients, and clinical decision criteria for WBCT are needed.
Collapse
|
7
|
Frequency and characteristics of traumatic brain injury in restrained drivers involved in road traffic accidents. Acta Neurochir (Wien) 2018; 160:1921-1929. [PMID: 30116903 DOI: 10.1007/s00701-018-3656-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND While seatbelt is an important device protecting drivers from traumatic brain injury (TBI), it has rarely been reported how often and in what circumstances restrained drivers sustain TBI after road traffic accident (RTA). Whole-body computed tomography (WBCT) for blunt trauma patients may provide a unique opportunity to investigate the frequency and characteristics of TBI sustained by restrained drivers. METHODS A single-center, retrospective observational study was conducted using prospectively acquired data. Between January 2013 and December 2017, 409 restrained drivers (284 men/125 women, mean age of 45.0 ± 19.1 years) whose vehicle had been severely damaged in RTAs underwent WBCT for evaluation of injuries. Multivariate regression analysis was performed to identify variables predictive of TBI. Influence of collision patterns (frontal, lateral or rollover) on the frequency and severity of TBI was evaluated. Relationship between collision patterns and CT findings was also reviewed. RESULTS Thirty-one restrained drivers (7.6%) sustained TBI after RTA. The distribution of Glasgow Coma Scale (GCS) scores among the 31 drivers was 15 in 9, 13-14 in 9, 9-12 in 4, and ≤ 8 in 9, indicating that the majority of TBIs were classifiable as mild. The frequency of TBI in alert and oriented drivers, i.e., those with a GCS score of 15, was 2.9%. Multivariate regression analysis showed that both altered mental status (OR, 4.933; 95% CI, 1.135-21.431) and loss of consciousness (OR, 6.492; 95% CI, 1.669-25.249) were associated with TBI. The frequency of TBI tended to be higher in drivers with rollover collision than those with frontal collision (6 vs. 13%, p = 0.07). Interhemispheric acute subdural hematoma and subcortical petechial hemorrhage seemed to be characteristic CT findings in drivers with frontal and lateral collision, respectively. CONCLUSIONS The key finding of this study, i.e., that (1) TBI was observed in 7.6% of restrained drivers with severe vehicular damage, may provide useful information to neurosurgeons who take care of RTA victims. The majority of the TBIs were mild without need for neurosurgical intervention. While association may exist between type of collision and type of brain injury, further studies with prospective design are warranted.
Collapse
|
8
|
Smith MC, Barrera K, Schwartz T, Roudnitsky V. Multisystem Trauma: How Bad Can it Get? Am Surg 2017. [DOI: 10.1177/000313481708300505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael C. Smith
- Department of Surgery SUNY Downstate Medical Center Brooklyn, New York; and the Department of Surgery Kings County Hospital Center Brooklyn, New York
| | - Kaylene Barrera
- Department of Surgery SUNY Downstate Medical Center Brooklyn, New York; and the Department of Surgery Kings County Hospital Center Brooklyn, New York
| | - Tim Schwartz
- Department of Surgery SUNY Downstate Medical Center Brooklyn, New York; and the Department of Surgery Kings County Hospital Center Brooklyn, New York
| | - Valery Roudnitsky
- Department of Surgery SUNY Downstate Medical Center Brooklyn, New York; and the Department of Surgery Kings County Hospital Center Brooklyn, New York
| |
Collapse
|