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Tamme K, Acosta S, Biloslavo A, Björck M, Casian D, Damaskos D, Forbes A, Kase K, Kisand K, Lakbar I, Mihnovitš V, Murruste M, Mändul M, Nuzzo A, Padar M, Starkopf J, Visconti D, Reintam Blaser A. Biomarkers In Prediction of Acute Mesenteric Ischaemia: a prospective multicentre study (BIPAMI study): a study protocol. BMC Surg 2024; 24:201. [PMID: 38961419 PMCID: PMC11221143 DOI: 10.1186/s12893-024-02491-3] [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: 03/19/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Acute mesenteric ischaemia (AMI) is a life-threatening disease where early diagnosis is critical to avoid morbidity and mortality from extensive irreversible bowel necrosis. Appropriate prediction of presence of bowel necrosis is currently not available but would help to choose the optimal method of treatment. The study aims to identify combinations of biomarkers that can reliably identify AMI and distinguish between potentially reversible and irreversible bowel ischaemia. METHODS This is a prospective multicentre study. Adult patients with clinical suspicion of AMI (n = 250) will be included. Blood will be sampled on admission, at and after interventions, or during the first 48 h of suspicion of AMI if no intervention undertaken. Samples will be collected and the following serum or plasma biomarkers measured at Tartu University Hospital laboratory: intestinal fatty acid-binding protein (I-FABP), alpha-glutathione S-transferase (Alpha- GST), interleukin 6 (IL-6), procalcitonin (PCT), ischaemia-modified albumin (IMA), D-lactate, D-dimer, signal peptide-CUB-EGF domain-containing protein 1 (SCUBE-1) and lipopolysaccharide-binding protein (LBP). Additionally, more common laboratory markers will be measured in routine clinical practice at study sites. Diagnosis of AMI will be confirmed by computed tomography angiography, surgery, endoscopy or autopsy. Student's t or Wilcoxon rank tests will be used for comparisons between transmural vs. suspected (but not confirmed) AMI (comparison A), confirmed AMI of any stage vs suspected AMI (comparison B) and non-transmural AMI vs transmural AMI (comparison C). Optimal cut-off values for each comparison will be identified based on the AUROC analysis and likelihood ratios calculated. Positive likelihood ratio > 10 (> 5) and negative likelihood ratio < 0.1 (< 0.2) indicate high (moderate) diagnostic accuracy, respectively. All biomarkers with at least moderate accuracy will be entered as binary covariates (using the best cutoffs) into the multivariable stepwise regression analysis to identify the best combination of biomarkers for all comparisons separately. The best models for each comparison will be used to construct a practical score to distinguish between no AMI, non-transmural AMI and transmural AMI. DISCUSSION As a result of this study, we aim to propose a score including set of biomarkers that can be used for diagnosis and decision-making in patients with suspected AMI. TRIAL REGISTRATION NCT06212921 (Registration Date 19-01-2024).
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Affiliation(s)
- Kadri Tamme
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
- Tartu University Hospital, Tartu, Estonia.
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Alan Biloslavo
- General Surgery Department, Cattinara University Hospital, Trieste, Italy
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Dumitru Casian
- Department of General Surgery Nr. 3, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Moldova
- Vascular Surgery Clinic, Institute of Emergency Medicine, Chisinau, Moldova
| | - Dimitrios Damaskos
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Karri Kase
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Kalle Kisand
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Ines Lakbar
- Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, University of Montpellier, Montpellier, France
| | - Vladislav Mihnovitš
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Marko Murruste
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Merli Mändul
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Alexandre Nuzzo
- Department of Gastroenterology, IBD and Intestinal Failure, Intestinal Stroke Center, AP-HP. Nord, Beaujon Hospital, Paris Cité University, Paris, France
| | | | - Joel Starkopf
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | | | - Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
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Reintam Blaser A, Björck M. Authors' Perspective of the Highlights, Limitations, and Future Directions of the Acute MESenteric Ischaemia (AMESI) Study. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00554-9. [PMID: 38914365 DOI: 10.1016/j.ejvs.2024.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/24/2024] [Accepted: 06/20/2024] [Indexed: 06/26/2024]
Affiliation(s)
- Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Martin Björck
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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Shi Y, Zhou Y, Yuan Y, Kong J, Gong M, Chen L, He X, Su H, Gu J. Establishment of an acute arterial mesenteric ischaemia model in canines with an endovascular approach. Front Vet Sci 2024; 11:1373914. [PMID: 38948676 PMCID: PMC11212455 DOI: 10.3389/fvets.2024.1373914] [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: 01/22/2024] [Accepted: 06/04/2024] [Indexed: 07/02/2024] Open
Abstract
Purpose This study aimed to evaluate the feasibility of establishing an arterial acute mesenteric ischemia (AMI) model in canines using transcatheter autologous thrombus administration. Materials and methods Ten canines were divided into the experimental group (Group A, n = 5) and the sham group (Group B, n = 5). The canines in Group A received thrombus administration to the superior mesenteric artery (SMA) through a guiding catheter, while the canines in Group B received normal saline administration. Blood samples were collected and tested at baseline and 2 h after modelling. Canines in Group A underwent manual thromboaspiration after blood and intestine samples were collected. Ischaemic grades of intestinal mucosa were evaluated under light microscopes. Results The AMI models were successfully conducted in all canines without procedure-related vessel injury or death. At the 2-h follow-up, the high-sensitivity C-reactive protein and D-dimer in Group A were significantly higher than in Group B (5.72 ± 1.8 mg/L vs. 2.82 ± 1.5 mg/L, p = 0.024; 2.25 ± 0.8 μg/mL vs. 0.27 ± 0.10 μg/mL, p = 0.005; respectively). The mean histopathologic intestinal ischaemic grade in Group A was significantly higher than in Group B (2.4 ± 0.5 vs. 0.8 ± 0.4, p < 0.001). After a median of 2 times of thromboaspiration, 80% (4/5) of the canines achieved complete SMA revascularisation. Conclusion This experimental study demonstrated that establishing an arterial model in canines using endovascular approaches was feasible. The present model may play an important role in the investigation of endovascular techniques in the treatment of arterial AMI.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jianping Gu
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Pfister F, Mehdorn M, Schwartner C, Seehofer D, Tautenhahn HM, Struck MF, Denecke T, Meyer HJ. Portal venous contrast enhancement ratio of the adrenal glands and spleen as prognostic marker of mortality in patients with acute mesenteric ischemia. Abdom Radiol (NY) 2024; 49:1376-1384. [PMID: 38528270 PMCID: PMC11108938 DOI: 10.1007/s00261-024-04247-2] [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: 12/14/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE Contrast enhancement of the adrenal gland defined by computed tomography (CT) was previously analyzed as a prognostic factor for critically ill patients in various diseases. However, no study investigated this quantitative parameter in patients with acute mesenteric ischemia. Therefore, the aim of this study was to evaluate the prognostic value of the contrast enhancement of the adrenal glands in patients with clinically suspected AMI. METHODS All patients with clinically suspected AMI were retrospectively assessed between 2016 and 2020. All patients underwent surgical exploration after CT imaging. Overall, 134 patients (52 female patients, 38.8%) with a mean age of 69.2 ± 12.4 years were included into the present analysis. For all patients, the preoperative CT was used to calculate the contrast media enhancement of the adrenal glands and the spleen. RESULTS A total of 27 patients (18.5%) died within the first 24 h and over the following 30-day 94 patients (68.6%) died. There were statistically significant differences regarding the mean values for adrenal-to-spleen ratio for 24-h mortality (p = 0.001) and 30-day mortality (p = 0.004), whereas the radiodensity of the inferior vena cava and the radiodensity of the spleen was statistically significant between survivors and non-survivors after 30 days (p = 0.037 and p = 0.028, respectively). In Cox regression analysis, mean adrenal radiodensity was associated with 24-h mortality (HR 1.09, 95% CI 1.02-1.16, p = 0.01) but not with 30-day mortality (HR 1.03, 95% CI 0.99-1.07, p = 0.13). CONCLUSION The contrast media enhancement of the adrenal gland is associated with the 24-h and 30-day mortality in patients with AMI. However, the prognostic relevance for translation into clinical routine needs to be validated in other cohorts.
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Affiliation(s)
- Felix Pfister
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Matthias Mehdorn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, Leipzig, Germany
| | - Christoph Schwartner
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, Leipzig, Germany
| | - Hans-Michael Tautenhahn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, Leipzig, Germany
| | - Manuel Florian Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Hans-Jonas Meyer
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany.
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
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Theodore S, Xia T, Saillant N. The Evaluation and Management of Intestinal Ischemia. NEJM EVIDENCE 2024; 3:EVIDra2400057. [PMID: 38776634 DOI: 10.1056/evidra2400057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
AbstractIntestinal ischemia can result from various pathologic conditions. The presentations of ischemia can range from acute to subacute and mild to severe. Diagnosis of this condition may pose challenges, particularly in the early, potentially salvageable, stages of disease. This review offers an evidence-based approach to understanding the diagnosis and management of inadequate intestinal perfusion.
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Affiliation(s)
- Sheina Theodore
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, Boston
| | - Tony Xia
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, Boston
| | - Noelle Saillant
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, Boston University School of Medicine, Boston
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Patel JJ, Lopez-Delgado JC, Stoppe C, McClave SA. Enteral nutrition in septic shock: a call for a paradigm shift. Curr Opin Crit Care 2024; 30:165-171. [PMID: 38441124 DOI: 10.1097/mcc.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to identify contemporary evidence evaluating enteral nutrition in patients with septic shock, outline risk factors for enteral feeding intolerance (EFI), describe the conundrum of initiating enteral nutrition in patients with septic shock, appraise current EFI definitions, and identify bedside monitors for guiding enteral nutrition therapy. RECENT FINDINGS The NUTRIREA-2 and NUTRIREA-3 trial results have better informed the dose of enteral nutrition in critically ill patients with circulatory shock. In both trials, patients with predominant septic shock randomized to receive early standard-dose nutrition had more gastrointestinal complications. Compared to other contemporary RCTs that included patients with circulatory shock, patients in the NUTRIREA-2 and NUTRIREA-3 trials had higher bowel ischemia rates, were sicker, and received full-dose enteral nutrition while receiving high baseline dose of vasopressor. These findings suggest severity of illness, vasopressor dose, and enteral nutrition dose impact outcomes. SUMMARY The provision of early enteral nutrition preserves gut barrier functions; however, these benefits are counterbalanced by potential complications of introducing luminal nutrients into a hypo-perfused gut, including bowel ischemia. Findings from the NUTRIREA2 and NUTRIREA-3 trials substantiate a 'less is more' enteral nutrition dose strategy during the early acute phase of critical illness. In the absence of bedside tools to guide the initiation and advancement of enteral nutrition in patients with septic shock, the benefit of introducing enteral nutrition on preserving gut barrier function must be weighed against the risk of harm by considering dose of vasopressor, dose of enteral nutrition, and severity of illness.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Christian Stoppe
- University Hospital, Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Stephen A McClave
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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Reintam Blaser A, Mändul M, Björck M, Acosta S, Bala M, Bodnar Z, Casian D, Demetrashvili Z, D'Oria M, Durán Muñoz-Cruzado V, Forbes A, Fuglseth H, Hellerman Itzhaki M, Hess B, Kase K, Kirov M, Lein K, Lindner M, Loudet CI, Mole DJ, Murruste M, Nuzzo A, Saar S, Scheiterle M, Starkopf J, Talving P, Voomets AL, Voon KKT, Yunus MA, Tamme K. Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study). Crit Care 2024; 28:32. [PMID: 38263058 PMCID: PMC10807222 DOI: 10.1186/s13054-024-04807-4] [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: 11/18/2023] [Accepted: 01/12/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND The aim of this multicentre prospective observational study was to identify the incidence, patient characteristics, diagnostic pathway, management and outcome of acute mesenteric ischaemia (AMI). METHODS All adult patients with clinical suspicion of AMI admitted or transferred to 32 participating hospitals from 06.06.2022 to 05.04.2023 were included. Participants who were subsequently shown not to have AMI or had localized intestinal gangrene due to strangulating bowel obstruction had only baseline and outcome data collected. RESULTS AMI occurred in 0.038% of adult admissions in participating acute care hospitals worldwide. From a total of 705 included patients, 418 patients had confirmed AMI. In 69% AMI was the primary reason for admission, while in 31% AMI occurred after having been admitted with another diagnosis. Median time from onset of symptoms to hospital admission in patients admitted due to AMI was 24 h (interquartile range 9-48h) and time from admission to diagnosis was 6h (1-12 h). Occlusive arterial AMI was diagnosed in 231 (55.3%), venous in 73 (17.5%), non-occlusive (NOMI) in 55 (13.2%), other type in 11 (2.6%) and the subtype could not be classified in 48 (11.5%) patients. Surgery was the initial management in 242 (58%) patients, of which 59 (24.4%) underwent revascularization. Endovascular revascularization alone was carried out in 54 (13%), conservative treatment in 76 (18%) and palliative care in 46 (11%) patients. From patients with occlusive arterial AMI, revascularization was undertaken in 104 (45%), with 40 (38%) of them in one site admitting selected patients. Overall in-hospital and 90-day mortality of AMI was 49% and 53.3%, respectively, and among subtypes was lowest for venous AMI (13.7% and 16.4%) and highest for NOMI (72.7% and 74.5%). There was a high variability between participating sites for most variables studied. CONCLUSIONS The overall incidence of AMI and AMI subtypes varies worldwide, and case ascertainment is challenging. Pre-hospital delay in presentation was greater than delays after arriving at hospital. Surgery without revascularization was the most common management approach. Nearly half of the patients with AMI died during their index hospitalization. Together, these findings suggest a need for greater awareness of AMI, and better guidance in diagnosis and management. TRIAL REGISTRATION NCT05218863 (registered 19.01.2022).
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Affiliation(s)
- Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia.
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Merli Mändul
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Martin Björck
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Zsolt Bodnar
- Letterkenny University Hospital, Letterkenny, Ireland
| | - Dumitru Casian
- University Clinic of Vascular Surgery, "Nicolae Testemitanu" State University of Medicine and Pharmacy of the Republic of Moldova, Chişinău, Moldova
| | | | - Mario D'Oria
- University Hospital of Trieste ASUGI, Trieste, Italy
| | | | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
| | - Hanne Fuglseth
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Moran Hellerman Itzhaki
- Intensive Care Unit and Institute for Nutrition Research, Rabin Medical Center, University of Tel Aviv, Petah Tikva, Israel
| | - Benjamin Hess
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Karri Kase
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Tartu University Hospital, Puusepa 8, Tartu, Estonia
| | - Mikhail Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University and City Hospital #1, Arkhangelsk, Russia
| | - Kristoffer Lein
- University Hospital North Norway and UiT The Arctic University of Norway, Tromsö, Norway
| | - Matthias Lindner
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Damian J Mole
- Chair of Surgery, University of Edinburgh Centre for Inflammation Research, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Marko Murruste
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Tartu University Hospital, Puusepa 8, Tartu, Estonia
| | - Alexandre Nuzzo
- Intestinal Stroke Center, Department of Gastroenterology, IBD and Intestinal Failure, AP-HP. Nord, Beaujon Hospital, Paris Cité University, Paris, France
| | - Sten Saar
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | | | - Joel Starkopf
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Tartu University Hospital, Puusepa 8, Tartu, Estonia
| | - Peep Talving
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | | | | | - Mohammad Alif Yunus
- General Surgeon of General Surgery Department, Hospital Melaka, Malacca, Malaysia
| | - Kadri Tamme
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Tartu University Hospital, Puusepa 8, Tartu, Estonia
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