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Abourisha E, Srinivasan AS, Barakat A, Chong HH, Singh HP. Surgical management of cubital tunnel syndrome: A systematic review and meta-analysis of randomised trials. J Orthop 2024; 53:41-48. [PMID: 38456175 PMCID: PMC10915370 DOI: 10.1016/j.jor.2024.02.041] [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: 02/11/2024] [Accepted: 02/24/2024] [Indexed: 03/09/2024] Open
Abstract
Background Cubital tunnel syndrome (CUTS) is a common upper limb compression neuropathy with significant consequences when left untreated. Surgical decompression remains gold-standard treatment for moderate to severe disease, however the optimal operative technique remains unclear. This network meta-analysis (NMA) of Level I and II randomised prospective studies aims to discern superiority between open in-situ, endoscopic and anterior transposition (subcutaneous or submuscular techniques) with respect to the primary outcome of response-to-treatment and secondary outcomes which include complications, post-operative chronic pain VAS scale, return to work and re-operation. Methods This NMA adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, Web of Science, Cochrane Central, Science direct and Embase were searched. The MESH database was further searched with the terms 'cubital tunnel' to improve sensitivity of the search. Data pertaining to the primary and secondary outcomes were pooled for NMA. Results Following abstract and full-text screening, 10 randomised prospective trials were included. There was no statistical difference in the response-to-treatment between the four studied techniques. Endoscopic decompression conferred a significantly higher complication rate compared to open decompression (Odds Ratio [OR], 4.21; 95% CI, 1.22-14.59). Endoscopic decompression had a statistically significant lower risk of post-operative chronic pain compared to open in-situ decompression (OR, 0.03, 95% CI, 0.00-0.32). There were no differences between techniques with respect to return to work or re-operation rates. Conclusion Response-to-treatment was similar between the four operative techniques for CUTS. Endoscopic decompression was found to be more hazardous when compared to open-in situ decompression but conferred significantly less post-operative chronic pain. There was significant heterogeneity in reported outcomes between the included articles. The authors suggest conducting more high-quality research with standardised outcome reporting to facilitate comparison. Level of evidence ii Systematic Review and Meta-analysis of Randomised Prospective Trials- Therapeutic study.
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Affiliation(s)
- Eslam Abourisha
- Trauma and Orthopaedic Department, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Ananth S. Srinivasan
- Trauma and Orthopaedic Department, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Ahmed Barakat
- Trauma and Orthopaedic Department, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Han Hong Chong
- Trauma and Orthopaedic Department, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
| | - Harvinder P. Singh
- Trauma and Orthopaedic Department, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK
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Shelke S, Ambade R, Shelke A. From Conservative Measures to Surgical Interventions, Treatment Approaches for Cubital Tunnel Syndrome: A Comprehensive Review. Cureus 2023; 15:e51262. [PMID: 38288228 PMCID: PMC10823195 DOI: 10.7759/cureus.51262] [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: 10/04/2023] [Accepted: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
Cubital tunnel syndrome (CuTS) is a neuropathic condition characterized by the compression or irritation of the ulnar nerve at the elbow, resulting in a wide spectrum of symptoms ranging from pain and numbness to muscle weakness and impaired hand function. This comprehensive review delves into the diverse landscape of CuTS treatment approaches, emphasizing the importance of early intervention. The review explores how these strategies aim to alleviate symptoms and enhance patient well-being by beginning with conservative measures encompassing rest, splinting, medications, physical therapy, and lifestyle adjustments. Non-surgical medical interventions, including nerve gliding exercises, ultrasound-guided nerve injections, and orthotic devices, are considered alternative therapies for symptom relief. Surgical interventions, such as decompression procedures and emerging techniques, are discussed in detail, highlighting their indications and expected outcomes. Throughout this review, the critical role of patient-centered care is underscored, emphasizing the need for tailored treatment plans that respect individual preferences and goals. Recognizing the unique nature of each CuTS case, shared decision-making between patients and healthcare providers is advocated, ensuring that interventions align with specific patient needs. As research advances, promising developments in diagnosis, surgical techniques, and drug therapies offer hope for more effective management of CuTS, paving the way for improved symptom relief and enhanced nerve function.
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Affiliation(s)
- Saurabh Shelke
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Ratnakar Ambade
- Orthopaedic Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Aditi Shelke
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Anderson D, Woods B, Abubakar T, Koontz C, Li N, Hasoon J, Viswanath O, Kaye AD, Urits I. A Comprehensive Review of Cubital Tunnel Syndrome. Orthop Rev (Pavia) 2022; 14:38239. [PMID: 36128335 PMCID: PMC9476617 DOI: 10.52965/001c.38239] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Cubital Tunnel Syndrome (CuTS) is the compression of the ulnar nerve as it courses through the cubital tunnel near the elbow at the location colloquially referred to as the "funny bone". CuTS is the most commonly diagnosed mononeuropathy after carpal tunnel syndrome. Cubital tunnel syndrome can manifest as numbness, tingling, or pain in the ring/small fingers and dorsoulnar hand. Repetitive pressure, stretching, flexion, or trauma of the elbow joint are known causes of CuTS. Chronic ulnar nerve compression and CuTS, when left untreated, can lead to atrophy of the first dorsal interosseus muscle and affect one's quality of life to the point that they are no longer able to participate in daily activities involving fine motor function. It is estimated that up to 5.9% of the general population have had symptoms of CuTS. CuTS is underdiagnosed due to lack of seeking of treatment for symptoms. Compression or damage to the ulnar nerve is the main cause of symptoms experienced by an individual with CuTS. Repetitive elbow pressure or a history or elbow joint trauma or injury are additional known causes that can lead to CuTS. Common presentations of CuTS include paresthesia, clumsiness of the hand, hand atrophy and weakness. The earliest sign of CuTS is most commonly numbness and tingling of the ring and 5th finger. Older patients tend to present with motor symptoms of chronic onset; younger patients tend to have more acute symptoms. Pain and point tenderness at the medial elbow may also be seen. CuTS lacks universally agreed upon diagnostic and treatment algorithms. CuTS can be diagnosed by physical exam using Tinel's sign, flexion-compression tests, palpating the ulnar nerve for thickening presence of local tenderness along the nerve. Ultrasound and nerve conduction studies may be used in combination with physical exam for diagnosis. Conservative treatment for CuTS is almost always pursued before surgical treatment and includes elbow splints, braces, and night-gliding exercises. Surgical treatment may be pursued in severe CuTS refractory to conservative treatment. Surgical options include open and endoscopic in-situ decompression, medial epicondylectomy, and anterior transposition of the ulnar nerve. CuTS is a prevalent disease that, if left untreated, can significantly alter an individual's quality of life. Therefore, an accurate diagnosis and appropriate treatment is paramount in reducing further damage and preventing worsening or future symptoms.
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Affiliation(s)
| | - Bison Woods
- Medical School, Medical College of Wisconsin
| | - Tunde Abubakar
- School of Medicine, Louisiana State University Health Science Center Shreveport
| | - Colby Koontz
- School of Medicine, Louisiana State University Health Science Center Shreveport
| | - Nathan Li
- Medical School, Medical College of Wisconsin
| | - Jamal Hasoon
- Anesthesiology, Beth Israel Deaconess Medical Center-Harvard Medical School
| | - Omar Viswanath
- Anesthesiology, Beth Israel Deaconess Medical Center-Harvard Medical School
| | - Alan D Kaye
- School of Medicine, Louisiana State University Health Science Center Shreveport
| | - Ivan Urits
- Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School
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Cancio JM, Jones KA, Stanley B, Truax C, Nuelle JAV. Design and fabrication of the Cubital Tunnel Control Orthosis (CTCO). J Hand Ther 2021; 34:500-503. [PMID: 32854997 DOI: 10.1016/j.jht.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/26/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Jill M Cancio
- United States Army Institute of Surgical Research Burn Center, Ft. Sam Houston, TX, USA; Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, Ft. Sam Houston, TX, USA; Extremity Trauma and Amputation Center of Excellence, Ft. Sam Houston, TX, USA.
| | - Kelly A Jones
- Occupational Therapy Section, Department of Rehabilitation Medicine, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
| | - Brandon Stanley
- Senior Leader Sustainment, US Army Sergeants Major Academy, William Beaumont Army Medical Center, Ft. Bliss, TX, USA
| | - Chelsea Truax
- Department of Rehabilitation Medicine, United States Army Health Clinic Vilseck, Rose Barracks, Vilseck, Germany
| | - Julia A V Nuelle
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Ft. Sam Houston, TX, USA
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Wade RG, Griffiths TT, Flather R, Burr NE, Teo M, Bourke G. Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis. JAMA Netw Open 2020; 3:e2024352. [PMID: 33231636 PMCID: PMC7686867 DOI: 10.1001/jamanetworkopen.2020.24352] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Cubital tunnel syndrome is the second most common compressive neuropathy, affecting 6% of the population. Numerous different operations are performed globally to treat it; however, prior conventional (pairwise) meta-analyses have been unable to determine which procedure is associated with the best outcomes and fewest complications. OBJECTIVE To evaluate which operation for cubital tunnel syndrome is associated with the greatest likelihood of symptomatic cure. DATA SOURCES PubMed, EMBASE, and CENTRAL were searched from database inception to March 2, 2019, with no restrictions on the setting or design of studies. STUDY SELECTION Experimental and observational studies directly comparing the outcomes of at least 2 surgical treatments for adults with primary cubital tunnel syndrome were included. Case reports were excluded, and when comparative studies had subgroups with 1 participant, the single-participant subgroup was excluded. The treatments had to be in situ decompression with or without medial epicondylectomy or an anterior subcutaneous, subfascial, intramuscular, or submuscular transposition. The access could be open, minimally invasive, or endoscopic. The comparator could be sham surgery or any operation mentioned earlier. DATA EXTRACTION AND SYNTHESIS Data were extracted by 2 independent reviewers, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the PRISMA Network Meta-analysis extension statement. Network meta-analysis was used to estimate the relative efficacy and safety associated with interventions using relative risks. Surgical techniques were ranked by their probability of being the best (P score) and interpreted in terms of their clinical impact. MAIN OUTCOMES AND MEASURES The primary outcome was response to treatment (ie, symptomatic improvement). The secondary outcomes were perioperative complications, reoperation, and recurrence. RESULTS A total of 30 studies of 2894 limbs undergoing 8 different operations were included. Across the studies, 56% of participants were men, the mean (SD) age was 48 (8) years, and patients had symptoms for a mean (SD) of 15 (7) months. Overall, 87% (95% CI, 92%-91%) of patients improved with surgery; all forms of in situ decompression were more effective than any type of transposition procedure; for example, open in situ decompression with epicondylectomy was associated with higher success rates than subcutaneous transposition (relative risk, 1.13; 95% CI, 1.01-1.25). Postoperatively, 3% (95% CI, 2%-4%) of patients developed complications, and in situ decompressions were ranked as the least risky, although there was considerable uncertainty in this outcome. Overall, 2% (95% CI, 1%-3%) of patients required reoperation; open in situ decompression was associated with the fewest reoperations; in comparison, submuscular transposition was associated with 5 times the risk of reoperation (relative risk, 5.08; 95% CI, 2.06-12.52). During surveillance, 3% (95% CI, 1%-4%) of patients developed recurrence, and open in situ decompression with epicondylectomy was ranked as the safest operation, although there was uncertainty in the estimates. CONCLUSIONS AND RELEVANCE In this network meta-analysis, open in situ decompression (with or without medial epicondylectomy) appeared to be the safest operation and also was associated with the best outcomes for patients with primary cubital tunnel syndrome. Future research should focus on better defining this disorder and developing core outcome measures.
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Affiliation(s)
- Ryckie G. Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom
| | - Timothy T. Griffiths
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom
| | - Robert Flather
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom
| | - Nicholas E. Burr
- Cancer Epidemiology Group, Institute of Cancer and Pathology and Institute of Data Analytics, University of Leeds, United Kingdom
- Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Mario Teo
- Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
| | - Grainne Bourke
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom
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Roth Bettlach CL, Hasak JM, Krauss EM, Yu JL, Skolnick GB, Bodway GN, Kahn LC, Mackinnon SE. Preferences in Sleep Position Correlate With Nighttime Paresthesias in Healthy People Without Carpal Tunnel Syndrome. Hand (N Y) 2019; 14:163-171. [PMID: 29020829 PMCID: PMC6436122 DOI: 10.1177/1558944717735942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carpal tunnel syndrome has been associated with sleep position preferences. The aim of this study is to assess self-reported nocturnal paresthesias and sleeping position in participants with and without carpal tunnel syndrome diagnosis to further clinical knowledge for preventive and therapeutic interventions. METHODS A cross-sectional survey study of 396 participants was performed in young adults, healthy volunteers, and a patient population. Participants were surveyed on risk factors for carpal tunnel syndrome, nocturnal paresthesias, and sleep preferences. Binary logistic regression analysis was performed comparing participants with rare and frequent nocturnal paresthesias. Subanalyses for participants without carpal tunnel syndrome under and over 21 years of age were performed on all factors significantly associated with subclinical compression neuropathy in the overall population. RESULTS Thirty-three percent of the study population experienced nocturnal paresthesias at least weekly. Increased body mass index ( P < .001) and sleeping with the wrist flexed ( P = .030) were associated with a higher frequency of nocturnal paresthesias. Side sleeping was associated with less frequent nocturnal symptoms ( P = .003). In participants without carpal tunnel syndrome, subgroup analysis illustrated a relationship between nocturnal paresthesias and wrist position. In participants with carpal tunnel syndrome, sleeping on the side had a significantly reduced frequency of nocturnal paresthesias. CONCLUSION This study illustrates nocturnal paresthesias in people without history of carpal tunnel syndrome including people younger than previously reported. In healthy patients with upper extremity subclinical compression neuropathy, sleep position modification may be a useful intervention to reduce the frequency of nocturnal symptoms prior to developing carpal tunnel syndrome.
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Affiliation(s)
| | - Jessica M. Hasak
- Washington University School of Medicine
in Saint Louis, MO, USA
| | | | - Jenny L. Yu
- Washington University School of Medicine
in Saint Louis, MO, USA
| | - Gary B. Skolnick
- Washington University School of Medicine
in Saint Louis, MO, USA
| | - Greta N. Bodway
- Washington University School of Medicine
in Saint Louis, MO, USA
| | - Lorna C. Kahn
- Washington University School of Medicine
in Saint Louis, MO, USA
| | - Susan E. Mackinnon
- Washington University School of Medicine
in Saint Louis, MO, USA,Susan E. Mackinnon, Division of Plastic
& Reconstructive Surgery, Department of Surgery, Washington University
School of Medicine in Saint Louis, 660 South Euclid Avenue, Campus Box 8238,
Saint Louis, MO 63110, USA.
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Boone S, Gelberman RH, Calfee RP. The Management of Cubital Tunnel Syndrome. J Hand Surg Am 2015; 40:1897-904; quiz 1904. [PMID: 26243318 DOI: 10.1016/j.jhsa.2015.03.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 03/03/2015] [Accepted: 03/07/2015] [Indexed: 02/02/2023]
Abstract
Symptomatic cubital tunnel syndrome is a condition that frequently prompts patients to seek hand surgical care. Although cubital tunnel syndrome is readily diagnosed, achieving complete symptom resolution remains challenging. This article reviews related anatomy, clinical presentation, and current management options for cubital tunnel syndrome with an emphasis on contemporary outcomes research.
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Affiliation(s)
- Sean Boone
- Department of Orthopedic Surgery, Washington University in St. Louis School of Medicine, St Louis, MO
| | - Richard H Gelberman
- Department of Orthopedic Surgery, Washington University in St. Louis School of Medicine, St Louis, MO
| | - Ryan P Calfee
- Department of Orthopedic Surgery, Washington University in St. Louis School of Medicine, St Louis, MO.
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Shah CM, Calfee RP, Gelberman RH, Goldfarb CA. Outcomes of rigid night splinting and activity modification in the treatment of cubital tunnel syndrome. J Hand Surg Am 2013; 38:1125-1130.e1. [PMID: 23647638 PMCID: PMC3989882 DOI: 10.1016/j.jhsa.2013.02.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 02/15/2013] [Accepted: 02/21/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To prospectively analyze, using validated outcome measures, symptom improvement in patients with mild to moderate cubital tunnel syndrome treated with rigid night splinting and activity modifications. METHODS Nineteen patients (25 extremities) were enrolled prospectively between August 2009 and January 2011 following a diagnosis of idiopathic cubital tunnel syndrome. Patients were treated with activity modifications as well as a 3-month course of rigid night splinting maintaining 45° of elbow flexion. Treatment failure was defined as progression to operative management. Outcome measures included patient-reported splinting compliance as well as the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire and the Short Form-12. Follow-up included a standardized physical examination. Subgroup analysis included an examination of the association between splinting success and ulnar nerve hypermobility. RESULTS Twenty-four of 25 extremities were available at mean follow-up of 2 years (range, 15-32 mo). Twenty-one of 24 (88%) extremities were successfully treated without surgery. We observed a high compliance rate with the splinting protocol during the 3-month treatment period. Quick Disabilities of the Arm, Shoulder, and Hand scores improved significantly from 29 to 11, Short Form-12 physical component summary score improved significantly from 45 to 54, and Short Form-12 mental component summary score improved significantly from 54 to 62. Average grip strength increased significantly from 32 kg to 35 kg, and ulnar nerve provocative testing resolved in 82% of patients available for follow-up examination. CONCLUSIONS Rigid night splinting when combined with activity modification appears to be a successful, well-tolerated, and durable treatment modality in the management of cubital tunnel syndrome. We recommend that patients presenting with mild to moderate symptoms consider initial treatment with activity modification and rigid night splinting for 3 months based on a high likelihood of avoiding surgical intervention. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Chirag M Shah
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA
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Abstract
Successful treatment of cubital tunnel syndrome requires obtaining a history of the physical and environmental factors involved for each patient, conducting a thorough physical examination, and staging and implementing an individually tailored treatment plan. Rest and avoiding pressure on the nerve by activity modification might be sufficient. If symptoms persist, splint immobilization of the elbow is warranted. Keep in mind that the natural history of untreated cubital tunnel syndrome includes spontaneous improvement in approximately half of patients.
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Affiliation(s)
- Robert M Szabo
- Department of Orthopaedic Surgery, University of California, Davis School of Medicine, 4860 Y Street, Suite 3800, Sacramento, CA 95817, USA.
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