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Ross L, McKelvie P, Reardon K, Wong H, Wicks I, Day J. Muscle biopsy practices in the evaluation of neuromuscular disease: A systematic literature review. Neuropathol Appl Neurobiol 2023; 49:e12888. [PMID: 36734037 PMCID: PMC10946625 DOI: 10.1111/nan.12888] [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: 09/23/2022] [Revised: 01/26/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023]
Abstract
AIMS Muscle biopsy techniques range from needle muscle biopsy (NMB) and conchotome biopsy to open surgical biopsy. It is unknown whether specific biopsy techniques offer superior diagnostic yield or differ in procedural complication rates. Therefore, we aimed to compare the diagnostic utility of NMB, conchotome and open muscle biopsies in the assessment of neuromuscular disorders. METHODS A systematic literature review of the EMBASE and Medline (Ovid) databases was performed to identify original, full-length research articles that described the muscle biopsy technique used to diagnose neuromuscular disease in both adult and paediatric patient populations. Studies of any design, excluding case reports, were eligible for inclusion. Data pertaining to biopsy technique, biopsy yield and procedural complications were extracted. RESULTS Sixty-four studies reporting the yield of a specific muscle biopsy technique and, or procedural complications were identified. Open surgical biopsies provided a larger tissue sample than any type of percutaneous muscle biopsy. Where anaesthetic details were reported, general anaesthesia was required in 60% of studies that reported open surgical biopsies. Percutaneous biopsies were most commonly performed under local anaesthesia and despite the smaller tissue yield, moderate- to large-gauge needle and conchotome muscle biopsies had an equivalent diagnostic utility to that of open surgical muscle biopsy. All types of muscle biopsy procedures were well tolerated with few adverse events and no scarring complications were reported with percutaneous sampling. CONCLUSIONS When a histological diagnosis of myopathy is required, moderate- to large-gauge NMB and the conchotome technique appear to have an equivalent diagnostic yield to that of an open surgical biopsy.
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Affiliation(s)
- Laura Ross
- Department of RheumatologySt Vincent's Hospital MelbourneFitzroyVictoriaAustralia
- Department of MedicineThe University of Melbourne at St Vincent's HospitalFitzroyVictoriaAustralia
| | - Penny McKelvie
- Department of Anatomical PathologySt Vincent's Hospital MelbourneFitzroyVictoriaAustralia
| | - Katrina Reardon
- Department of NeurologySt Vincent's Hospital MelbourneFitzroyVictoriaAustralia
| | - Huon Wong
- Inflammation DivisionWalter and Eliza Hall Institute of Medical ResearchParkvilleVictoriaAustralia
| | - Ian Wicks
- Inflammation DivisionWalter and Eliza Hall Institute of Medical ResearchParkvilleVictoriaAustralia
- Department of RheumatologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
- Department of Medical BiologyUniversity of MelbourneParkvilleVictoriaAustralia
| | - Jessica Day
- Inflammation DivisionWalter and Eliza Hall Institute of Medical ResearchParkvilleVictoriaAustralia
- Department of RheumatologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
- Department of Medical BiologyUniversity of MelbourneParkvilleVictoriaAustralia
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Devkota S, Shrestha S, Gurung T, Shrestha S. Regional anesthesia as a safe option in patient with limb girdle muscular dystrophy undergoing total abdominal hysterectomy: A case report and case review. Clin Case Rep 2022; 10:e6523. [PMID: 36381058 PMCID: PMC9637942 DOI: 10.1002/ccr3.6523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/25/2022] [Accepted: 10/08/2022] [Indexed: 11/09/2022] Open
Abstract
Regional anesthesia can be a very safe option in patients with limb girdle muscular dystrophy undergoing lower abdominal surgeries as general anesthesia and volatile anesthetic agents are associated with increased risk of malignant hyperthermia and rhabdomyolysis.
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Affiliation(s)
- Sagar Devkota
- Department of Anesthesiology and Critical Care Sindhuli Hospital Sindhuli Nepal
| | | | - Tara Gurung
- Department of Anesthesiology PMWH Kathmandu Nepal
| | - Saurav Shrestha
- Department of Anesthesiology and Critical Care Nepal APF Hospital Kathmandu Nepal
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Abstract
Neuromuscular diseases (NMD) are a heterogeneous group of motor unit disorders. Common to all is the main clinical symptom of muscle weakness. Depending on entity and phenotype, a broad range of disorders of neuronal, junctional or myocytic structures occurs. In addition to a weakness of the skeletal musculature, NMD can also affect throat musculature, respiratory and heart muscles. The possible consequences are immobility, deformities, tendency to aspiration as well as respiratory and cardiac insufficiency. In the context of surgery and anesthesia, complications that can result from the underlying disease and its interaction with anesthesia must be anticipated and averted. This article describes along the treatment pathway how preoperative evaluation, choice of the anesthetic procedure and postoperative care can be effectively and safely tailored to the needs of patients with NMD. Concise and practical recommendations for carrying out anesthesia for the most important NMDs are presented as well as relevant external sources of practice recommendations.
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4
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Cung S, Ritz ML, Masaracchia MM. Regional anesthesia in pediatric patients with preexisting neurological disease. Paediatr Anaesth 2021; 31:522-530. [PMID: 33590927 DOI: 10.1111/pan.14152] [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: 10/08/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 12/01/2022]
Abstract
Preexisting neurological disease in pediatric patients presents unique challenges to the anesthesiologist. In-depth knowledge of the disease processes and awareness of sequalae that uniquely influence the risks and benefits of anesthetics are needed to make informed decisions. Because these vulnerable populations are often susceptible to perioperative airway or cardiopulmonary complications, the use of regional anesthesia can be advantageous. However, these clinical conditions already involve compromised neural tissue and, as such, create additional concern that regional anesthesia may result in new or worsened deficits. The following discussion is not intended to be a full review of each disease process, but rather provides a concise, yet thorough, discussion of the available literature on regional anesthesia in the more common, but still rare, pediatric neurological disorders. We aim to provide a framework for pediatric anesthesiologists to reengage in a healthy discussion about the risks and benefits of utilizing regional anesthesia in this vulnerable population.
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Affiliation(s)
- Stephanie Cung
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Matthew L Ritz
- Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Melissa M Masaracchia
- University of Colorado School of Medicine, Aurora, CO, USA.,Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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Pansini V, Curatola A, Gatto A, Lazzareschi I, Ruggiero A, Chiaretti A. Intranasal drugs for analgesia and sedation in children admitted to pediatric emergency department: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:189. [PMID: 33569491 PMCID: PMC7867955 DOI: 10.21037/atm-20-5177] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute pain is one of the most common symptoms in children admitted to the Pediatric Emergency Department (PED) and its management represents a real clinical challenge for pediatricians. Different painful procedures can be very stressful for young children and their perception of pain can be enhanced by emotional factors, such as anxiety, distress, or anger. Adequate procedural sedation reduces anxiety and emotional trauma for the patient, but it reduces also stress for operators and the time for procedures. We have reviewed the literature on this topic and the drugs covered in these papers were: midazolam, fentanyl, ketamine, and dexmedetomidine. There are several routes of administering for these drugs to provide analgesia and anxiolysis to children: oral, parenteral, or intranasal (IN). Intravenous (IV) sedation, since it involves the use of needles, can be stressful; instead, IN route is a non-invasive procedure and generally well tolerated by children and it has become increasingly widespread. Some medications can be administered by a mucosal atomizer device (MAD) or by drops. The benefits of the atomized release include less drug loss in the oropharynx, higher cerebrospinal fluid levels, better patient acceptability, and better sedative effects. IN midazolam has a sedative, anxiolytic and amnesic effect, but without analgesic properties. Fentanyl and ketamine are mainly used for pain control. Dexmedetomidine has anxiolytic and analgesic properties. In conclusion, IN analgo-sedation is a simple, rapid and painless option to treat pain and anxiety in the PED requiring brief training on the administration process and experience in sedation.
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Affiliation(s)
- Valeria Pansini
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italia
| | - Antonietta Curatola
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Gatto
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Roma, Italia
| | - Ilaria Lazzareschi
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Antonio Chiaretti
- Dipartimento di Pediatria, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
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Ishida Y, Morita M, Sasaki T, Taniguchi A. Spinal anesthesia for muscle biopsy in an infant with a suspected neuromuscular disorder: a case report. JA Clin Rep 2020; 6:84. [PMID: 33078243 PMCID: PMC7572997 DOI: 10.1186/s40981-020-00392-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 11/30/2022] Open
Abstract
Background Neuromuscular disorders (NMDs) occur in different forms and are generally diagnosed using muscle biopsy. Among the available anesthetic management options for infants with a suspected NMD are general anesthesia (GA) and regional anesthesia (RA), including spinal anesthesia (SA). Anesthesia selection is often challenging from the point of potential airway risks and anesthetic drug-related complications. Case presentation A 6-month-old male infant repeatedly underwent endotracheal intubation and extubation after birth because of respiratory muscle weakness and copious secretions. He was suspected of having NMD and was scheduled for muscle biopsy. His generalized hypotonia and decreased respiratory function presented a potentially difficult airway and complicated the selection of an appropriate anesthetic method. We selected SA and dexmedetomidine, which are safe for infants. Conclusion We report the successful and effective anesthetic management of SA and dexmedetomidine in an infant with a suspected NMD.
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Cote DR, Fuentes E, Elsayes AH, Ross JJ, Quraishi SA. A "crush" course on rhabdomyolysis: risk stratification and clinical management update for the perioperative clinician. J Anesth 2020; 34:585-598. [PMID: 32424487 DOI: 10.1007/s00540-020-02792-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 05/09/2020] [Indexed: 12/14/2022]
Abstract
Rhabdomyolysis, the release of myoglobin and other cellular breakdown products from necrotic muscle tissue, is seen in patients with crush injuries, drug overdose, malignant hyperthermia, muscular dystrophy, and with increasing frequency in obese patients undergoing routine procedures. For the perioperative clinician, managing the resultant shock, hyperkalemia, acidosis, and myoglobinuric acute kidney injury can present a significant challenge. Prompt recognition, hydration, and correction of metabolic disturbances may reduce or eliminate the need for long-term renal replacement therapy. This article reviews the pathophysiology and discusses key issues in the perioperative diagnosis, risk stratification, and management of rhabdomyolysis.
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Affiliation(s)
- Devan R Cote
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Eva Fuentes
- Department of Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Ali H Elsayes
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA
| | - Jonathan J Ross
- Department of Anesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA
| | - Sadeq A Quraishi
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, Boston, MA, 02111, USA.
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Zeeni C, Karam CJ, Kaddoum RN, Aouad MT. Propofol use in children: updates and controversies. Minerva Anestesiol 2020; 86:433-444. [DOI: 10.23736/s0375-9393.19.14022-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Patino M, Chandrakantan A. Midgestational Fetal Procedures. CASE STUDIES IN PEDIATRIC ANESTHESIA 2019:197-201. [DOI: 10.1017/9781108668736.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Anesthetic management of a patient with limb-girdle muscular dystrophy 2B:CARE-compliant case report and literature review. BMC Anesthesiol 2019; 19:155. [PMID: 31421689 PMCID: PMC6698341 DOI: 10.1186/s12871-019-0813-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/29/2019] [Indexed: 11/24/2022] Open
Abstract
Background Limb-girdle muscular dystrophies (LGMDs) belong to few neuromuscular disorders mainly involving pelvic and shoulder girdle muscles. Also, cardiac or pulmonary complications, increased rhabdomyolysis risk when exposed to volatile anesthetics and succinylcholine may increase anesthesia related risks. However, current reports about the anesthesia management of these patients are limited. Case presentation We described our anesthetic management of a 36 years old woman with LGMD 2B receiving arthroscopic knee surgery. In consideration of the high risk of rhabdomyolysis, total intravenous anesthesia (TIVA) was selected for her surgery. Considering the unpredictable respiratory depression, opioid based patient-controlled intravenous analgesia was replaced with an intra-articular cocktail therapy consisting of 20 ml of 0.2% ropivacaine. Also, we reviewed the literatures on anesthetic management of LGMD through searching PubMed, in order to provide a comprehensive and safe guidance for the surgery. Conclusions Carefully conducted general anesthesia with TIVA technique is a good choice for LGMD patients. Neuraxial anesthesia may be used if general anesthesia needs to be avoided. To warrant safe anesthesia for surgery, any decision must be well thought out during perioperative period.
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12
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Practicalities of Total Intravenous Anesthesia and Target-controlled Infusion in Children. Anesthesiology 2019; 131:164-185. [DOI: 10.1097/aln.0000000000002657] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Propofol administered in conjunction with an opioid such as remifentanil is used to provide total intravenous anesthesia for children. Drugs can be given as infusion controlled manually by the physician or as automated target-controlled infusion that targets plasma or effect site. Smart pumps programmed with pharmacokinetic parameter estimates administer drugs to a preset plasma concentration. A linking rate constant parameter (keo) allows estimation of effect site concentration. There are two parameter sets, named after the first author describing them, that are commonly used in pediatric target-controlled infusion for propofol (Absalom and Kataria) and one for remifentanil (Minto). Propofol validation studies suggest that these parameter estimates are satisfactory for the majority of children. Recommended target concentrations for both propofol and remifentanil depend on the type of surgery, the degree of surgical stimulation, the use of local anesthetic blocks, and the ventilatory status of the patient. The use of processed electroencephalographic monitoring is helpful in pediatric total intravenous anesthesia and target-controlled infusion anesthesia, particularly in the presence of neuromuscular blockade.
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Yang K, Iannaccone S, Burkhalter LS, Reisch J, Cai C, Schindel D. Role of Nerve and Muscle Biopsies in Pediatric Patients in the Era of Genetic Testing. J Surg Res 2019; 243:27-32. [PMID: 31151034 DOI: 10.1016/j.jss.2019.04.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/11/2019] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND An operative biopsy is an important component in the diagnosis and treatment of neuromuscular disorders (NMDs). However, recent advances in molecular genetics suggest less invasive genetic testing should be the initial approach. The purpose of our study was to demonstrate the diagnostic value of muscle or nerve biopsy within the pediatric population at a pediatric academic center and offer recommendations for genetic testing in relation to biopsy to achieve the highest diagnostic yield. METHODS Following institutional review board approval, we retrospectively reviewed the electronic medical record of 221 pediatric patients who underwent muscle and/or nerve biopsy for suspicion of NMD from January 2007 to March 2018. Demographics, family history, clinical presentations, genetic testing results, pathology results, anesthesia complications, clinical diagnoses, and clinic follow-up data were collected. Chi-square analysis was done for statistical significance. RESULTS A total of 220 underwent muscle biopsy, and 15 underwent nerve biopsy. Not all patients received genetic testing. The average age at biopsy was 7.7 y. Biopsy revealed significant histologic abnormalities in 62.9% (139), directly leading to a specific clinical diagnosis in 33.9% (75). When genetic testing was done before biopsy, definite pathogenic variants were found in 7.6% (9). When genetic testing was done after biopsy, definite pathogenic variants were found in 45.0% (27). Genetic testing yield for pathogenic variants was higher when done after biopsy (P value < 0.00001). CONCLUSIONS Muscle and nerve biopsies may provide significant diagnostic value. Biopsy helped to rule in or out NMD and guide genetic testing. Our data suggest NMD genetic testing yield was higher when done after biopsy.
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Affiliation(s)
- Kaili Yang
- Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Susan Iannaccone
- Pediatric Surgery, Children's Medical Center, Dallas, Texas; Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lorrie S Burkhalter
- Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Pediatric Surgery, Children's Medical Center, Dallas, Texas
| | - Joan Reisch
- Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chunyu Cai
- Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David Schindel
- Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Pediatric Surgery, Children's Medical Center, Dallas, Texas.
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Multidisciplinary Perioperative Care for Children with Neuromuscular Disorders. CHILDREN-BASEL 2018; 5:children5090126. [PMID: 30213079 PMCID: PMC6162674 DOI: 10.3390/children5090126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/07/2018] [Indexed: 12/27/2022]
Abstract
Children with neuromuscular diseases present unique challenges to providing safe and appropriate perioperative care. Given the spectrum of disease etiologies and manifestations, this is a population that often requires specialized multidisciplinary care from pediatricians, geneticists, neurologists, dieticians, and pulmonologists which must also be coordinated with surgeons and anesthesiologists when these patients present for surgery. Several of these diseases also have specific pharmacologic implications for anesthesia, most notably mitochondrial disease and muscular dystrophies, which put them at additional risk during the perioperative period particularly in patients presenting without a formal diagnosis. Techniques and strategies to fully evaluate and optimize these patients preoperatively, manage them safely intraoperatively, and return them to their baseline status postoperative are particularly important in this vulnerable group of patients. Utilizing a review of inherited neuromuscular conditions, generalized perioperative concerns, and specific complications related to anesthesia, this article provides an overview of pertinent considerations and recommends a framework for management of these patients.
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Abstract
This review identifies disease states associated with malignant hyperthermia susceptibility based on genotypic and phenotypic findings, and a framework is established for clinicians to identify a potentially malignant hyperthermia–susceptible patient.
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Kloesel B, Holzman RS. Anesthetic Management of Patients With Inborn Errors of Metabolism. Anesth Analg 2017; 125:822-836. [DOI: 10.1213/ane.0000000000001689] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Gray RM. Anesthesia-induced rhabdomyolysis or malignant hyperthermia: is defining the crisis important? Paediatr Anaesth 2017; 27:490-493. [PMID: 28306187 DOI: 10.1111/pan.13130] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2017] [Indexed: 12/11/2022]
Abstract
Anesthesia-induced rhabdomyolysis and malignant hyperthermia occur in response to the same agents and present with similar clinical features. Distinguishing between these diagnoses can be challenging in a clinical crisis yet making the distinction is critical as prompt appropriate management may be life-saving, whereas delayed recognition and/or inappropriate management will almost certainly result in death. This focused review examines the differences between these conditions and focuses on the emergency management of anesthesia-induced rhabdomyolysis.
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Affiliation(s)
- Rebecca M Gray
- Division of Paediatric Anaesthesia, Department of Anaesthesia and PeriOperative Medicine, University of Cape Town, Cape Town, South Africa
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Brandom BW, Byler D. Anesthesia for muscle biopsy: when nothing bad happened, was no special care needed? Paediatr Anaesth 2016; 26:680-1. [PMID: 27277650 DOI: 10.1111/pan.12923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Barbara W Brandom
- The North American MH Registry of MHAUS, UPMC Mercy Hospital, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Debra Byler
- Department Pediatrics and Neurology, Penn State College of Medicine, Hershey, PA, USA
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