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Khan SA, Demidowich AP, Tschudy MM, Wedler J, Lamy W, Akpandak I, Alexander LA, Misra I, Sidhaye A, Rotello L, Zilbermint M. Increasing Frequency of Hemoglobin A1c Measurements in Hospitalized Patients With Diabetes: A Quality Improvement Project Using Lean Six Sigma. J Diabetes Sci Technol 2024; 18:866-873. [PMID: 36788726 DOI: 10.1177/19322968231153883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND The American Diabetes Association (ADA) recommends measuring A1c in all inpatients with diabetes if not performed in the prior three months. Our objective was to determine the impact of utilizing Lean Six Sigma to increase the frequency of A1c measurements in hospitalized patients. METHODS We evaluated inpatients with diabetes mellitus consecutively admitted in a community hospital between January 2016 and June 2021, excluding those who had an A1c in the electronic health record (EHR) in the previous three months. Lean Six Sigma was utilized to define the extent of the problem and devise solutions. The intervention bundle delivered between November 2017 and February 2018 included (1) provider education on the utility of A1c, (2) more rapid turnaround of A1c results, and (3) an EHR glucose-management tab and insulin order set that included A1c. Hospital encounter and patient-level data were extracted from the EHR via bulk query. Frequency of A1c measurement was compared before (January 2016-November 2017) and after the intervention (March 2018-June 2021) using χ2 analysis. RESULTS Demographics did not differ preintervention versus postintervention (mean age [range]: 70.9 [18-104] years, sex: 52.2% male, race: 57.0% white). A1c measurements significantly increased following implementation of the intervention bundle (61.2% vs 74.5%, P < .001). This level was sustained for more than two years following the initial intervention. Patients seen by the diabetes consult service (40.4% vs 51.7%, P < 0.001) and length of stay (mean: 135 hours vs 149 hours, P < 0.001) both increased postintervention. CONCLUSIONS We demonstrate a novel approach in improving A1c in hospitalized patients. Lean Six Sigma may represent a valuable methodology for community hospitals to improve inpatient diabetes care.
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Affiliation(s)
- Sara Atiq Khan
- Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew P Demidowich
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Megan M Tschudy
- Division of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joyce Wedler
- Department of Information Systems, Suburban Hospital, Bethesda, MD, USA
| | - Wilson Lamy
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iniuboho Akpandak
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Lee Ann Alexander
- Department of Pharmacy, Suburban Hospital, Johns Hopkins Medicine, Bethesda, MD, USA
| | - Isha Misra
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Aniket Sidhaye
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Leo Rotello
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
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Shi J, Chen F, Zheng K, Su T, Wang X, Wu J, Ni B, Pan Y. Clinical nomogram prediction model to assess the risk of prolonged ICU length of stay in patients with diabetic ketoacidosis: a retrospective analysis based on the MIMIC-IV database. BMC Anesthesiol 2024; 24:86. [PMID: 38424557 PMCID: PMC10902986 DOI: 10.1186/s12871-024-02467-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 02/23/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The duration of hospitalization, especially in the intensive care unit (ICU), for patients with diabetic ketoacidosis (DKA) is influenced by patient prognosis and treatment costs. Reducing ICU length of stay (LOS) in patients with DKA is crucial for optimising healthcare resources utilization. This study aimed to establish a nomogram prediction model to identify the risk factors influencing prolonged LOS in ICU-managed patients with DKA, which will serve as a basis for clinical treatment, healthcare safety, and quality management research. METHODS In this single-centre retrospective cohort study, we performed a retrospective analysis using relevant data extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Clinical data from 669 patients with DKA requiring ICU treatment were included. Variables were selected using the Least Absolute Shrinkage and Selection Operator (LASSO) binary logistic regression model. Subsequently, the selected variables were subjected to a multifactorial logistic regression analysis to determine independent risk factors for prolonged ICU LOS in patients with DKA. A nomogram prediction model was constructed based on the identified predictors. The multivariate variables included in this nomogram prediction model were the Oxford acute severity of illness score (OASIS), Glasgow coma scale (GCS), acute kidney injury (AKI) stage, vasoactive agents, and myocardial infarction. RESULTS The prediction model had a high predictive efficacy, with an area under the curve value of 0.870 (95% confidence interval [CI], 0.831-0.908) in the training cohort and 0.858 (95% CI, 0.799-0.916) in the validation cohort. A highly accurate predictive model was depicted in both cohorts using the Hosmer-Lemeshow (H-L) test and calibration plots. CONCLUSION The nomogram prediction model proposed in this study has a high clinical application value for predicting prolonged ICU LOS in patients with DKA. This model can help clinicians identify patients with DKA at risk of prolonged ICU LOS, thereby enhancing prompt intervention and improving prognosis.
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Affiliation(s)
- Jincun Shi
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Fujin Chen
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Kaihui Zheng
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Tong Su
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Xiaobo Wang
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Jianhua Wu
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Bukao Ni
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China
| | - Yujie Pan
- Department of Critical Care Medicine, Wenzhou Central Hospital, Wenzhou, Zhejiang, 325000, China.
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Balintescu A, Rysz S, Hertz C, Grip J, Cronhjort M, Oldner A, Svensen C, Mårtensson J. Prevalence and impact of chronic dysglycaemia among patients with COVID-19 in Swedish intensive care units: a multicentre, retrospective cohort study. BMJ Open 2023; 13:e071330. [PMID: 37730398 PMCID: PMC10510869 DOI: 10.1136/bmjopen-2022-071330] [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: 12/23/2022] [Accepted: 08/29/2023] [Indexed: 09/22/2023] Open
Abstract
OBJECTIVE Using glycated haemoglobin A1c (HbA1c) screening, we aimed to determine the prevalence of chronic dysglycaemia among patients with COVID-19 admitted to the intensive care unit (ICU). Additionally, we aimed to explore the association between chronic dysglycaemia and clinical outcomes related to ICU stay. DESIGN Multicentre retrospective observational study. SETTING ICUs in three hospitals in Stockholm, Sweden. PARTICIPANTS COVID-19 patients admitted to the ICU between 5 March 2020 and 13 August 2020 with available HbA1c at admission. Chronic dysglycaemia was determined based on previous diabetes history and HbA1c. PRIMARY AND SECONDARY OUTCOMES Primary outcome was the actual prevalence of chronic dysglycaemia (pre-diabetes, unknown diabetes or known diabetes) among COVID-19 patients. Secondary outcome was the association of chronic dysglycaemia with 90-day mortality, ICU length of stay, duration of invasive mechanical ventilation (IMV) and renal replacement therapy (RRT), accounting for treatment selection bias. RESULTS A total of 308 patients with available admission HbA1c were included. Chronic dysglycaemia prevalence assessment was restricted to 206 patients admitted ICUs in which HbA1c was measured on all admitted patients. Chronic dysglycaemia was present in 82.0% (95% CI 76.1% to 87.0%) of patients, with pre-diabetes present in 40.2% (95% CI 33.5% to 47.3%), unknown diabetes in 20.9% (95% CI 15.5% to 27.1%), well-controlled diabetes in 7.8% (95% CI 4.5% to 12.3%) and uncontrolled diabetes in 13.1% (95% CI 8.8% to 18.5%). All patients with available HbA1c were included for the analysis of the relationship between chronic dysglycaemia and secondary outcomes. We found no independent association between chronic dysglycaemia and 90-day mortality, ICU length of stay or duration of IMV. After excluding patients with specific treatment limitations, no association between chronic dysglycaemia and RRT use was observed. CONCLUSIONS In our cohort of critically ill COVID-19 patients, the prevalence of chronic dysglycaemia was 82%. We found no robust associations between chronic dysglycaemia and clinical outcomes when accounting for treatment limitations.
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Affiliation(s)
- Anca Balintescu
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Susanne Rysz
- Department of Perioperative Medicine and Intensive Care, Karolinska Institute, Stockholm, Sweden
| | - Carl Hertz
- Department of Anesthesia and Intensive Care, Stockholm South General Hospital Anaesthesia, Stockholm, Sweden
| | - Jonathan Grip
- Department of Perioperative Medicine and Intensive Care, Karolinska Institute, Stockholm, Sweden
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Anders Oldner
- Department of Perioperative Medicine and Intensive Care, Karolinska Institute, Stockholm, Sweden
| | - Christer Svensen
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Johan Mårtensson
- Department of Perioperative Medicine and Intensive Care, Karolinska Institute, Stockholm, Sweden
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Mårtensson J, Cutuli SL, Osawa EA, Yanase F, Toh L, Cioccari L, Luethi N, Maeda A, Bellomo R. Sodium glucose co-transporter-2 inhibitors in intensive care unit patients with type 2 diabetes: a pilot case control study. Crit Care 2023; 27:189. [PMID: 37194077 DOI: 10.1186/s13054-023-04481-y] [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: 03/17/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Sodium glucose co-transporter-2 (SGLT2) inhibitors improve long-term cardiovascular and renal outcomes in individuals with type 2 diabetes. However, the safety of SGLT2 inhibitors in ICU patients with type 2 diabetes is uncertain. We aimed to perform a pilot study to assess the relationship between empagliflozin therapy and biochemical, and clinical outcomes in such patients. METHODS We included 18 ICU patients with type 2 diabetes receiving empagliflozin (10 mg daily) and insulin to target glucose range of 10-14 mmol/l according to our liberal glucose control protocol for patients with diabetes (treatment group). Treatment group patients were matched on age, glycated hemoglobin A1c, and ICU duration with 72 ICU patients with type 2 diabetes exposed to the same target glucose range but who did not receive empagliflozin (control group). We compared changes in electrolyte and acid-base parameters, hypoglycemia, ketoacidosis, worsening kidney function, urine culture findings, and hospital mortality between the groups. RESULTS Median (IQR) maximum increase in sodium and chloride levels were 3 (1-10) mmol/l and 3 (2-8) mmol/l in the control group and 9 (3-12) mmol/l and 8 (3-10) mmol/l in the treatment group (P = 0.045 for sodium, P = 0.059 for chloride). We observed no differences in strong ion difference, pH or base excess. Overall, 6% developed hypoglycemia in each group. No patient in the treatment group and one patient in the control group developed ketoacidosis. Worsening kidney function occurred in 18% and 29% of treatment and control group patients, respectively (P = 0.54). Urine cultures were positive in 22% of treatment group patients and 13% of control group patients (P = 0.28). Overall, 17% of treatment group patients and 19% of control group patients died in hospital (P = 0.79). CONCLUSIONS In our pilot study of ICU patients with type 2 diabetes, empagliflozin therapy was associated with increases in sodium and chloride levels but was not significantly associated with acid-base changes, hypoglycemia, ketoacidosis, worsening kidney function, bacteriuria, or mortality.
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Affiliation(s)
- Johan Mårtensson
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden.
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, L.Go F. Vito 1, 00168, Rome, Italy
| | - Eduardo A Osawa
- Cardiology Intensive Care Unit, Hospital DF-Star, Brasília, Brazil
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Lisa Toh
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Luca Cioccari
- Department of Intensive Care Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Nora Luethi
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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Hanna M, Balintescu A, Glassford N, Lipcsey M, Eastwood G, Oldner A, Bellomo R, Mårtensson J. Glycemic lability index and mortality in critically ill patients-A multicenter cohort study. Acta Anaesthesiol Scand 2021; 65:1267-1275. [PMID: 33964015 DOI: 10.1111/aas.13843] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/19/2021] [Accepted: 04/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Emerging evidence indicates a relationship between glycemic variability during intensive care unit (ICU) admission and death. We assessed whether mean glucose, hypoglycemia occurrence, or premorbid glycemic control modified this relationship. METHODS In this retrospective, multicenter cohort study, we included adult patients admitted to five ICUs in Australia and Sweden with available preadmission glycated hemoglobin A1c (HbA1c) and three or more glucose readings. We calculated the glycemic lability index (GLI), a measure of glycemic variability, and the time-weighted average blood glucose (TWA-BG) from all glucose readings. We used logistic regression analysis with adjustment for hypoglycemia and admission characteristics to assess the independent association of GLI (above vs. below cohort median) and TWA-BG (above vs. below cohort median) with hospital mortality. RESULTS Among 2305 patients, 859 (37%) had diabetes, median GLI was 40 [mmol/L]2 /h/week, median TWA-BG was 8.2 mmol/L, 171 (7%) developed hypoglycemia, and 371 (16%) died. The adjusted odds ratio for death was 1.61 (95% CI, 1.19-2.15; P = .002) for GLI above versus below median and 1.06 (95% CI, 0.80-1.41; P = .67) for TWA-BG above versus below median. The relationship between GLI and mortality was not modified by TWA-BG (P [interaction] = 0.66), a history of diabetes (P [interaction] = 0.89) or by HbA1c ≥52 mmol/mol (vs. <52 mmol/mol) (P [interaction] = 0.29). CONCLUSION In adult patients admitted to an ICU in Sweden and Australia, a high GLI was associated with increased hospital mortality irrespective of the level of mean glycemia, hypoglycemia occurrence, or premorbid glycemic control. These findings support the assessment of interventions to reduce glycemic variability during critical illness.
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Affiliation(s)
- Michel Hanna
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
| | - Anca Balintescu
- Department of Clinical Science and Education Södersjukhuset Section of Anaesthesia and Intensive Care Karolinska Institutet Stockholm Sweden
| | - Neil Glassford
- Department of Intensive Care Austin Hospital Melbourne Australia
| | - Miklos Lipcsey
- Hedenstierna Laboratory Department of Surgical Sciences Section of Anaesthesiology and Intensive care Uppsala University Uppsala Sweden
| | - Glenn Eastwood
- Department of Intensive Care Austin Hospital Melbourne Australia
| | - Anders Oldner
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Section of Anaesthesia and Intensive Care Karolinska Institutet Stockholm Sweden
| | - Rinaldo Bellomo
- Department of Intensive Care Austin Hospital Melbourne Australia
| | - Johan Mårtensson
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Department of Physiology and Pharmacology Section of Anaesthesia and Intensive Care Karolinska Institutet Stockholm Sweden
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Roth* J, Sommerfeld* O, L. Birkenfeld A, Sponholz C, A. Müller U, von Loeffelholz C. Blood Sugar Targets in Surgical Intensive Care—Management and Special Considerations in Patients With Diabetes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:629-636. [PMID: 34857072 PMCID: PMC8715312 DOI: 10.3238/arztebl.m2021.0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/08/2021] [Accepted: 04/20/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND 30-80% of patients being treated in intensive care units in the perioperative period develop hyperglycemia. This stress hyperglycemia is induced and maintained by inflammatory-endocrine and iatrogenic stimuli and generally requires treatment. There is uncertainty regarding the optimal blood glucose targets for patients with diabetes mellitus. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed and Google Scholar. RESULTS Patients in intensive care with pre-existing diabetes do not benefit from blood sugar reduction to the same extent as metabolically healthy individuals, but they, too, are exposed to a clinically relevant risk of hypoglycemia. A therapeutic range from 4.4 to 6.1 mmol/L (79-110 mg/dL) cannot be justified for patients with diabetes mellitus. The primary therapeutic strategy in the perioperative setting should be to strictly avoid hypoglycemia. Neurotoxic effects and the promotion of wound-healing disturbances are among the adverse consequences of hyperglycemia. Meta-analyses have shown that an upper blood sugar limit of 10 mmol/L (180 mg/dL) is associated with better outcomes for diabetic patients than an upper limit of less than this value. The target range of 7.8-10 mmol/L (140-180 mg/dL) proposed by specialty societies for hospitalized patients with diabetes seems to be the best compromise at present for optimizing clinical outcomes while avoiding hypoglycemia. The method of choice for achieving this goal in intensive care medicine is the continuous intravenous administration of insulin, requirng standardized, high-quality monitoring conditions. CONCLUSION Optimal blood sugar control for diabetic patients in intensive care meets the dual objectives of avoiding hypoglycemia while keeping the blood glucose concentration under 10 mmol/L (180 mg/dL). Nutrition therapy in accordance with the relevant guidelines is an indispensable pre - requisite.
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Affiliation(s)
- Johannes Roth*
- *The authors contributed equally to this paper
- Dept. for Anesthesiology and Intensive Care Medicine, University Hospital of the Friedrich-Schiller University Jena, Jena, Germany
| | - Oliver Sommerfeld*
- *The authors contributed equally to this paper
- Dept. for Anesthesiology and Intensive Care Medicine, University Hospital of the Friedrich-Schiller University Jena, Jena, Germany
| | - Andreas L. Birkenfeld
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- King´s College London, Department of Diabetes, School of Life Course Science, London, UK
- Institute for Diabetes Research and Metabolic Diseases (IDM) of the Helmholtz Center Munich at the University of Tübingen, Germany
- Division IV (Diabetology, Endocrinology, Nephrology) of the Department of Internal Medicine at the University Hospital Tübingen, Germany
| | - Christoph Sponholz
- Dept. for Anesthesiology and Intensive Care Medicine, University Hospital of the Friedrich-Schiller University Jena, Jena, Germany
| | - Ulrich A. Müller
- Practice for Diabetology and Endocrinology, Dr. Kielstein, Outpatient Healthcare Center Erfurt, Jena
| | - Christian von Loeffelholz
- Dept. for Anesthesiology and Intensive Care Medicine, University Hospital of the Friedrich-Schiller University Jena, Jena, Germany
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