1
|
Hang G, Gong Y, Xie H, Xie T. A novel lateral myelotomy approach for the treatment of lateral or ventrolateral spinal gliomas. Acta Neurochir (Wien) 2024; 166:237. [PMID: 38809310 DOI: 10.1007/s00701-024-06139-2] [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: 04/17/2024] [Accepted: 05/22/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVE To describe a novel surgical approach in which myelotomy was performed lateral to the dorsal root entry zone (LDREZ), for the treatment of lateral or ventrolateral spinal intramedullary glioma. METHODS This study reviewed six patients with lateral or ventrolateral spinal intramedullary glioma who received surgical treatments by using myelotomy technique of LDREZ approach. The patient's clinical characteristics, magnetic resonance imaging (MRI) results, and follow-up outcomes were analyzed. The neurological function of patients before and after operation was assessed based on the Frankel scale system. The anatomical feasibility, surgical techniques, advantages and disadvantages of LDREZ approach were analyzed. RESULTS Myelotomy technique of LDREZ approach was employed in all 6 patients. Gross total resections were achieved in 4 patients, and 2 patients with astrocytoma (case 2, 6) underwent partial removal. The perioperative recovery was all smooth and all the patients were discharged on schedule. All the patients who suffered from neuropathic pain were relieved. After surgery, neurological function remained unchanged in 3 patients. 2 patients improved from Frankel grade B to C, and 1 patient deteriorated from Frankel grade D to C immediately after surgery and returned to Frankel grade D at 3 months follow-up. Regarding to the poor prognosis of high-grade glioma, the two cases with WHO IV glioma didn't achieve long survival. CONCLUSION LDREZ approach is feasible and safe for the surgical removal of lateral or ventrolateral spinal gliomas. This approach can provide a direct pathway to lateral or ventrolateral spinal gliomas with minimal damage to normal spinal cord.
Collapse
Affiliation(s)
- Gai Hang
- School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Yukang Gong
- School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Hang Xie
- School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Tianhao Xie
- Department of Neurosurgery, Central Theater General Hospital of Chinese PLA, Wuhan, China.
| |
Collapse
|
2
|
Aashita A, Sharma R, Yadav V, Manikandan M, Dhameliya A, Mishra H, Thakur P, Malik A. Primary Intramedullary Spinal High-Grade Glioma: A Case Series with Review of Literature. South Asian J Cancer 2024; 13:150-156. [PMID: 38919654 PMCID: PMC11196153 DOI: 10.1055/s-0042-1758570] [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: 12/04/2022] Open
Abstract
AashitaBackground Primary intramedullary high-grade glioma (HGG) and glioblastoma of spinal cord are uncommon tumors of central nervous system. Treatment recommendations are based on current guidelines of intracranial HGG and glioblastoma multiforme (GBM). Methods We retrospectively analyzed records of 9,686 patients who reported to our center over past 7 years. Only three cases of primary intramedullary HGG of spinal cord were found. Results In this article, we have reported three cases of primary intramedullary HGG of spinal cord. A comparison of intracranial and intramedullary spinal HGG and review of literature is presented. Conclusion Despite aggressive treatment using surgery, radiation, and chemotherapy, the survival rates are dismal. Emerging evidence has shown difference in biological behavior of intracranial and spinal HGG. Genetic studies to understand the biology and prospective studies are needed.
Collapse
Affiliation(s)
- Aashita Aashita
- Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Rajiv Sharma
- Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Vikas Yadav
- Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Muthu Manikandan
- Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Ankit Dhameliya
- Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Hemendra Mishra
- Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Pragyat Thakur
- Department of Radiation Oncology, Homi Bhabha Cancer Hospital, Sangrur (Affiliated to HBNI, Mumbai), Maharashtra, India
| | - Abhidha Malik
- Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
| |
Collapse
|
3
|
Jiang J, Li WB, Xiao SW. Prognostic factors analysis of diffuse midline glioma. J Neurooncol 2024; 167:285-292. [PMID: 38381257 PMCID: PMC11023999 DOI: 10.1007/s11060-024-04605-6] [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: 01/05/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE This study retrospectively analyzes cases of diffuse midline glioma treated with radiotherapy, with the aim of investigating the prognosis of the tumor and its influencing factors. METHODS From January 2018 to November 2022, we treated 64 patients who were pathologically diagnosed with diffuse midline glioma. Among them, 41 underwent surgical resection, and 23 underwent biopsy procedures. All patients received postoperative radiotherapy. We followed up with the patients to determine the overall survival rate and conducted univariate and multivariate analyses on relevant indicators. RESULTS The median survival time for the entire patient group was 33.3 months, with overall survival rates of 92.9%, 75.4%, and 45.0% at 1 year, 2 years, and 3 years, respectively. Univariate and multivariate analyses indicated that older patients had a better prognosis. CONCLUSION Patient age is an independent prognostic factor for patients with diffuse midline glioma undergoing radiation therapy.
Collapse
Affiliation(s)
- Jing Jiang
- Department of Neuro-oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100071, China
- Department of Radiation Oncology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, China
| | - Wen-Bin Li
- Department of Neuro-oncology, Cancer Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100071, China.
| | - Shao-Wen Xiao
- Department of Radiation Oncology, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, China.
| |
Collapse
|
4
|
Zhang F, Cheng L, Ding Z, Wang S, Zhao X, Zhao Z, Liang C, Wu K, Zhang D, Wang Y, Fan T. Does H3K27M Mutation Impact Survival Outcome of High-Grade Spinal Cord Astrocytoma? Neurospine 2023; 20:1480-1489. [PMID: 38171314 PMCID: PMC10762395 DOI: 10.14245/ns.2346650.325] [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: 06/06/2023] [Revised: 09/14/2023] [Accepted: 09/16/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE To evaluate the impact of H3K27M mutation in the prognosis of histological high-grade intramedullary astrocytoma. METHODS A total of 78 patients who were diagnosed with high-grade spinal cord astrocytoma were included. Clinical data consisting demographic, radiological, molecular features and treatment data were recorded. Univariate and multivariate Cox analysis were performed to investigate variables associated with survival outcome of histological high-grade spinal cord astrocytoma. RESULTS Median survival time was 21 months. Overall survival (OS) at 1 and 3 years was 65.7% and 40.7%, respectively. Sex, location, and tumor span did not present significant association with OS. Patients with H3K27M mutation showed significant shorter duration of symptom than patients with H3K27 wild-type. As respect to adjuvant treatment, adjuvant radiotherapy and chemotherapy were associated with favorable OS (both p = 0.01). Younger patients (age ≤ 18 years) had shorter OS (p = 0.008) than adult patients (age > 18 years). Of note, H3K27M mutation did not show significant impact on the survival outcome, regardless of histology grade 3 or grade 4 (p = 0.3). CONCLUSION Histological high-grade spinal cord astrocytoma has dismal prognosis. Our study demonstrated that H3K27M mutation did not show significant impact on survival outcome of histological high-grade spinal cord astrocytoma.
Collapse
Affiliation(s)
- Fan Zhang
- Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Lei Cheng
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
| | - Ze Ding
- Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Shengxi Wang
- Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xingang Zhao
- Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Zijun Zhao
- Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Cong Liang
- Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Kun Wu
- Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Dongao Zhang
- Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yinqian Wang
- Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Tao Fan
- Sanbo Brain Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
5
|
Adhikari S, Bhutada AS, Ladner L, Cuoco JA, Entwistle JJ, Marvin EA, Rogers CM. Prognostic Indicators for H3K27M-Mutant Diffuse Midline Glioma: A Population-Based Retrospective Surveillance, Epidemiology, and End Results Database Analysis. World Neurosurg 2023; 178:e113-e121. [PMID: 37423332 DOI: 10.1016/j.wneu.2023.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/02/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Diffuse midline glioma with histone H3K27M mutation (H3K27M DMG) is a recently recognized World Health Organization grade IV glioma with a dismal prognosis. Despite maximal treatment, this high-grade glioma exhibits an estimated median survival of 9-12 months. However, little is known with regards to prognostic risk factors for overall survival (OS) for patients with this malignant tumor. The aim of the present study is to characterize risk factors influencing survival in H3K27M DMG. METHODS This is a population-based retrospective study of survival in patients with H3K27M DMG. The Surveillance, Epidemiology, and End Results database was examined from the years 2018 to 2019 and data from 137 patients were collected. Basic demographics, tumor site, and treatments regimens were retrieved. Univariate and multivariable analyses were conducted to assess for factors associated with OS. Nomograms were built based on the results of the multivariable analyses. RESULTS Median OS of the entire cohort was 13 months. Patients with infratentorial H3K27M DMG exhibited worse OS compared to their supratentorial counterparts. Any form of radiation treatment resulted in a significantly improved OS. Most combination treatments significantly improved OS with the exception of the surgery plus chemotherapy group. The combination of surgery and radiation had the greatest impact on OS. CONCLUSIONS Overall, the infratentorial location of H3K27M DMG portends a worse prognosis compared to their supratentorial counterparts. The combination of surgery and radiation had the greatest impact on OS. These data highlight the survival benefit in utilizing a multimodal treatment approach for H3K27M DMG.
Collapse
Affiliation(s)
- Srijan Adhikari
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA.
| | | | - Liliana Ladner
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Joshua A Cuoco
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - John J Entwistle
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Eric A Marvin
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Cara M Rogers
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| |
Collapse
|
6
|
Tanaka Y, Hirano T, Ohashi M, Tashi H, Makino T, Minato K, Kawashima H, Kakita A, Hasegawa K, Watanabe K. Usefulness and limitations of intraoperative pathological diagnosis using frozen sections for spinal cord tumors. J Orthop Sci 2023:S0949-2658(23)00220-8. [PMID: 37635031 DOI: 10.1016/j.jos.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Intraoperative pathological diagnosis has a major influence on the intra- and postoperative management of spinal cord tumors. Thus, the aim of this study was to assess the reliability of intraoperative pathological diagnosis for spinal cord lesions by comparing it with the final pathological diagnosis and to determine its usefulness and limitations. METHOD Three-hundred and three consecutive patients (mean age, 53.9 years) with neoplastic spinal cord lesions who underwent initial surgery between 2000 and 2021 were included. The anatomical locations of the spinal cord tumors and the implementation rate of intraoperative pathological diagnosis in each tumor type were evaluated. As the primary outcome, we determined the concordance rates between the intraoperative pathological diagnosis and the final diagnosis. When the intraoperative pathological diagnosis and final diagnosis were the same, the diagnosis was defined as a "match." Otherwise, the diagnosis was defined as a "mismatch." RESULTS The overall implementation rate of intraoperative pathological diagnosis was 53%, with implementation rates of 71%, 45%, 47%, and 50% for intramedullary, intradural extramedullary, extradural, and dumbbell tumors, respectively. The overall concordance rate was 87.6%, with concordance rates of 80%, 95%, 75%, and 90% for intramedullary, intradural extramedullary, extradural, and dumbbell tumors, respectively (p < 0.05). The diagnoses of ependymomas, low-grade astrocytomas, and high-grade astrocytomas was occasionally difficult among intramedullary tumors. Among intradural extramedullary tumors, differentiation between grade 1 meningioma and high-grade meningioma was difficult using intraoperative pathological diagnosis. CONCLUSIONS Surgeons must recognize the lower accuracy of intraoperative pathological diagnosis for intramedullary and extradural lesions and make a final decision by considering the intraoperative gross findings, preoperative clinical course, and imaging.
Collapse
Affiliation(s)
- Yuki Tanaka
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan; Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Toru Hirano
- Department of Orthopedic Surgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-Uonuma City, Niigata, Japan
| | - Masayuki Ohashi
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hideki Tashi
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tatsuo Makino
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Keitaro Minato
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroyuki Kawashima
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Akiyoshi Kakita
- Department of Pathology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Kazuhiro Hasegawa
- Niigata Spine Surgery Center, Kameda Daiichi Hospital, Niigata, Japan
| | - Kei Watanabe
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan; Niigata Spine Surgery Center, Kameda Daiichi Hospital, Niigata, Japan.
| |
Collapse
|
7
|
Serrallach BL, Tran BH, Bauer DF, Mohila CA, Adesina AM, McGovern SL, Lindsay HB, Huisman TAGM. Pediatric spinal cord diffuse midline glioma, H3 K27-altered with intracranial and spinal leptomeningeal spread: A case report. Neuroradiol J 2022; 35:634-639. [PMID: 34989626 PMCID: PMC9513925 DOI: 10.1177/19714009211067402] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Primary spinal cord high-grade gliomas, including those histologically identified as glioblastoma (GBM), are a rare entity in the pediatric population but should be considered in the differential diagnosis of intramedullary lesions. Pediatric spinal cord high-grade gliomas have an aggressive course with poor prognosis. The aim of this case report is to present a 15-year-old female adolescent with histopathologically confirmed spinal cord GBM with H3F3A K27 M mutation consistent with a diffuse midline glioma (DMG), H3 K27-altered, CNS WHO grade 4 with leptomeningeal seeding on initial presentation. As imaging features of H3 K27-altered DMGs are non-specific and may mimic more frequently encountered neoplastic diseases as well as demyelinating disorders, severe neurological deficits at presentation with short duration, rapid progression, and early leptomeningeal seeding should however raise the suspicion for a pediatric-type diffuse high-grade glioma like DMG, H3 K27-altered.
Collapse
Affiliation(s)
- Bettina L Serrallach
- Edward B. Singleton Department of
Radiology, Texas Children’s Hospital and Baylor College of
Medicine, Houston, TX, USA
| | - Brandon H Tran
- Edward B. Singleton Department of
Radiology, Texas Children’s Hospital and Baylor College of
Medicine, Houston, TX, USA
| | - David F Bauer
- Department of Neurosurgery, Texas Children’s Hospital and Baylor College of
Medicine, Houston, TX, USA
| | - Carrie A Mohila
- Department of Pathology and Immunology, Texas Children’s Hospital and Baylor College of
Medicine, Houston, TX, USA
| | - Adekunle M Adesina
- Department of Pathology and Immunology, Texas Children’s Hospital and Baylor College of
Medicine, Houston, TX, USA
| | - Susan L McGovern
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer
Center, Houston, TX, USA
- Proton Therapy Center, The University of Texas MD Anderson Cancer
Center, Houston, TX, USA
| | - Holly B Lindsay
- Division of Pediatric Hematology and
Oncology, Department of Pediatrics, Texas Children’s Hospital and Baylor College of
Medicine, Houston, TX, USA
| | - Thierry AGM Huisman
- Edward B. Singleton Department of
Radiology, Texas Children’s Hospital and Baylor College of
Medicine, Houston, TX, USA
| |
Collapse
|
8
|
Vuong HG, Ngo TNM, Le HT, Jea A, Hrachova M, Battiste J, McNall-Knapp R, Dunn IF. Prognostic Implication of Patient Age in H3K27M-Mutant Midline Gliomas. Front Oncol 2022; 12:858148. [PMID: 35371982 PMCID: PMC8971724 DOI: 10.3389/fonc.2022.858148] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/28/2022] [Indexed: 01/02/2023] Open
Abstract
IntroductionPediatric and adult H3K27M-mutant midline gliomas have variable clinical presentations, prognoses, and molecular backgrounds. In this study, we integrated data from published studies to investigate the differences between these two groups.MethodsPubMed and Web of Science were searched for potential data. Studies were included if they had available individual participant data on patients age of H3K27M-mutant midline gliomas. For time-to-event analyses, Kaplan-Meier analysis and Cox regression models were carried out; corresponding hazard ratios (HR) and 95% confidence intervals (CI) were computed to analyze the impact of age and clinical covariates on progression-free survival (PFS) and overall survival (OS).ResultsWe included 43 studies comprising 272 adults and 657 pediatric midline gliomas with H3K27M mutation for analyses. In adults, there was a male predilection whereas females were slightly more common than males in the pediatric group. Spinal cord tumors were more frequent in adults. The prevalence of H3.1 K27M mutation was significantly higher in the pediatric cohort. Compared to adult patients, pediatric H3K27M-mutant midline gliomas exhibited more aggressive features including higher rates of pathologic features of high-grade tumors and Ki67 proliferation index, and had a shorter PFS and OS. Genetically, ACVR1 mutations were more common whereas MGMT methylation, FGFR1, and NF1 mutations were less prevalent in the pediatric cohort.ConclusionPediatric H3K27M-mutant midline gliomas were demographically, clinically, and molecularly distinct from adult patients, highlighting an opportunity to refine the risk stratification for these neoplasms.
Collapse
Affiliation(s)
- Huy Gia Vuong
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma University, Oklahoma City, OK, United States
| | - Tam N. M. Ngo
- Faculty of Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Hieu Trong Le
- Department of Pathology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Andrew Jea
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Oklahoma Children’s Hospital, The University of Oklahoma Health Sciences Center, Oklahoma University, Oklahoma City, OK, United States
| | - Maya Hrachova
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma University, Oklahoma City, OK, United States
| | - James Battiste
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma University, Oklahoma City, OK, United States
| | - Rene McNall-Knapp
- Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma University, Oklahoma City, OK, United States
| | - Ian F. Dunn
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma University, Oklahoma City, OK, United States
- *Correspondence: Ian F. Dunn,
| |
Collapse
|