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Jing HD, Tian JY, Li W, He BL, Li HC, Jian FX, Shang C, Shen F. Predictive performance of the variation rate of the driving pressure on the outcome of invasive mechanical ventilation in patients with acute respiratory distress syndrome. Chin J Traumatol 2024; 27:107-113. [PMID: 38326140 DOI: 10.1016/j.cjtee.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 12/06/2023] [Accepted: 12/18/2023] [Indexed: 02/09/2024] Open
Abstract
PURPOSE To assess the value of the driving pressure variation rate (ΔP%) in predicting the outcome of weaning from invasive mechanical ventilation in patients with acute respiratory distress syndrome. METHODS In this case-control study, a total of 35 patients with moderate-severe acute respiratory distress syndrome were admitted to the intensive care unit between January 2022 and December 2022 and received invasive mechanical ventilation for at least 48 h were enrolled. Patients were divided into successful weaning group and failed weaning group depending on whether they could be removed from ventilator support within 14 days. Outcome measures including driving pressure, PaO2:FiO2, and positive end-expiratory pressure, etc. were assessed every 24 h from day 0 to day 14 until successful weaning was achieved. The measurement data of non-normal distribution were presented as median (Q1, Q3), and the differences between groups were compared by Wilcoxon rank sum test. And categorical data use the Chi-square test or Fisher's exact test to compare. The predictive value of ΔP% in predicting the outcome of weaning from the ventilator was analyzed using receiver operating characteristic curves. RESULTS Of the total 35 patients included in the study, 17 were successful vs. 18 failed in weaning from a ventilator after 14 days of mechanical ventilation. The cut-off values of the median ΔP% measured by Operator 1 vs. Operator 2 in the first 4 days were ≥ 4.17% and 4.55%, respectively (p < 0.001), with the area under curve of 0.804 (sensitivity of 88.2%, specificity of 64.7%) and 0.770 (sensitivity of 88.2%, specificity of 64.7%), respectively. There was a significant difference in mechanical ventilation duration between the successful weaning group and the failure weaning group (8 (6, 13) vs. 12 (7.5, 17.3), p = 0.043). The incidence of ventilator-associated pneumonia in the successful weaning group was significantly lower than in the failed weaning group (0.2‰ vs. 2.3‰, p = 0.001). There was a significant difference noted between these 2 groups in the 28-day mortality (11.8% vs. 66.7%, p = 0.003). CONCLUSION The median ΔP% in the first 4 days of mechanical ventilation showed good predictive performance in predicting the outcome of weaning from mechanical ventilation within 14 days. Further study is needed to confirm this finding.
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Affiliation(s)
- Hui-Dan Jing
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China; Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Jun-Ying Tian
- College of Foreign Languages, Chongqing Medical University, Chongqing, 400016, China
| | - Wei Li
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Bing-Ling He
- Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Hong-Chao Li
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Fu-Xia Jian
- Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Cui Shang
- Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Feng Shen
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China.
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Rali AS, Tran LE, Auvil B, Xu M, Huang S, Labrada L, Schlendorf KH, Bacchetta MD, Shah AS, Hernandez A, Lindenfeld J. Modifiable Mechanical Ventilation Targets Are Associated With Improved Survival in Ventilated VA-ECLS Patients. JACC. HEART FAILURE 2023; 11:961-968. [PMID: 37178085 PMCID: PMC10171237 DOI: 10.1016/j.jchf.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/29/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND In acute respiratory distress syndrome (ARDS), lung protective ventilation (LPV) improves patient outcomes by minimizing ventilator-induced lung injury. The value of LPV in ventilated patients with cardiogenic shock (CS) requiring venoarterial extracorporeal life support (VA-ECLS) is not known, but the extracorporeal circuit provides a unique opportunity to modify ventilatory parameters to improve outcomes. OBJECTIVES The authors hypothesized that CS patients on VA-ECLS who require mechanical ventilation (MV) may benefit from low intrapulmonary pressure ventilation (LPPV), which has the same end goals as LPV. METHODS The authors queried the ELSO (Extracorporeal Life Support Organization) registry for hospital admissions between 2009 and 2019 for CS patients on VA-ECLS and MV. They defined LPPV as peak inspiratory pressure at 24 hours on ECLS of <30 cm H2O. Positive end-expiration pressure and dynamic driving pressure (DDP) at 24 hours were also studied as continuous variables. Their primary outcome was survival to discharge. Multivariable analyses were performed that adjusted for baseline Survival After Venoarterial Extracorporeal Membrane Oxygenation score, chronic lung conditions, and center extracorporeal membrane oxygenation volume. RESULTS A total of 2,226 CS patients on VA-ECLS were included: 1,904 received LPPV. The primary outcome was higher in the LPPV group vs the no-LPPV group (47.4% vs 32.6%; P < 0.001). Median peak inspiratory pressure (22 vs 24 cm H2O; P < 0.001) as well as DDP (14.5 vs 16 cm H2O; P < 0.001) were also significantly lower in those surviving to discharge. The adjusted OR for the primary outcome with LPPV was 1.69 (95% CI: 1.21-2.37; P = 0.0021). CONCLUSIONS LPPV is associated with improved outcomes in CS patients on VA-ECLS requiring MV.
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Affiliation(s)
- Aniket S Rali
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Lena E Tran
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan Auvil
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Lyana Labrada
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Raschke RA, Stoffer B, Assar S, Fountain S, Olsen K, Heise CW, Gallo T, Padilla-Jones A, Gerkin R, Parthasarathy S, Curry SC. The relationship of tidal volume and driving pressure with mortality in hypoxic patients receiving mechanical ventilation. PLoS One 2021; 16:e0255812. [PMID: 34370773 PMCID: PMC8351937 DOI: 10.1371/journal.pone.0255812] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/23/2021] [Indexed: 12/04/2022] Open
Abstract
PURPOSE To determine whether tidal volume/predicted body weight (TV/PBW) or driving pressure (DP) are associated with mortality in a heterogeneous population of hypoxic mechanically ventilated patients. METHODS A retrospective cohort study involving 18 intensive care units included consecutive patients ≥18 years old, receiving mechanical ventilation for ≥3 days, with a PaO2/FiO2 ratio ≤300 mmHg, whether or not they met full criteria for ARDS. The main outcome was hospital mortality. Multiple logistic regression (MLR) incorporated TV/PBW, DP, and potential confounders including age, APACHE IVa® predicted hospital mortality, respiratory system compliance (CRS), and PaO2/FiO2. Predetermined strata of TV/PBW were compared using MLR. RESULTS Our cohort comprised 5,167 patients with mean age 61.9 years, APACHE IVa® score 79.3, PaO2/FiO2 166 mmHg and CRS 40.5 ml/cm H2O. Regression analysis revealed that patients receiving DP one standard deviation above the mean or higher (≥19 cmH20) had an adjusted odds ratio for mortality (ORmort) = 1.10 (95% CI: 1.06-1.13, p = 0.009). Regression analysis showed a U-shaped relationship between strata of TV/PBW and adjusted mortality. Using TV/PBW 4-6 ml/kg as the referent group, patients receiving >10 ml/kg had similar adjusted ORmort, but those receiving 6-7, 7-8 and 8-10 ml/kg had lower adjusted ORmort (95%CI) of 0.81 (0.65-1.00), 0.78 (0.63-0.97) and 0.80 0.67-1.01) respectively. The adjusted ORmort in patients receiving 4-6 ml/kg was 1.26 (95%CI: 1.04-1.52) compared to patients receiving 6-10 ml/kg. CONCLUSIONS Driving pressures ≥19 cmH2O were associated with increased adjusted mortality. TV/PBW 4-6ml/kg were used in less than 15% of patients and associated with increased adjusted mortality compared to TV/PBW 6-10 ml/kg used in 82% of patients. Prospective clinical trials are needed to prove whether limiting DP or the use of TV/PBW 6-10 ml/kg versus 4-6 ml/kg benefits mortality.
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Affiliation(s)
- Robert A. Raschke
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Brenda Stoffer
- Information Technology, Banner Health, Phoenix, AZ, United States of America
| | - Seth Assar
- Pulmonary Critical Care Medicine Fellowship, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Stephanie Fountain
- Pulmonary Critical Care Medicine Fellowship, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Kurt Olsen
- Pulmonary Critical Care Medicine Fellowship, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - C. William Heise
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Tyler Gallo
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Angela Padilla-Jones
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
- Department of Medical Toxicology, Banner—University Medical Center Phoenix, Phoenix, AZ, United States of America
| | - Richard Gerkin
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
- Department of Medicine, Banner—University Medical Center—Phoenix, Phoenix, AZ, United States of America
| | - Sairam Parthasarathy
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine University of Arizona College of Medicine, Tucson, AZ, United States of America
| | - Steven C. Curry
- The Division of Clinical Data Analytics and Decision Support, Department of Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
- Department of Medical Toxicology, Banner—University Medical Center Phoenix, Phoenix, AZ, United States of America
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Pelosi P, Ball L, Barbas CSV, Bellomo R, Burns KEA, Einav S, Gattinoni L, Laffey JG, Marini JJ, Myatra SN, Schultz MJ, Teboul JL, Rocco PRM. Personalized mechanical ventilation in acute respiratory distress syndrome. Crit Care 2021; 25:250. [PMID: 34271958 PMCID: PMC8284184 DOI: 10.1186/s13054-021-03686-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 01/22/2023] Open
Abstract
A personalized mechanical ventilation approach for patients with adult respiratory distress syndrome (ARDS) based on lung physiology and morphology, ARDS etiology, lung imaging, and biological phenotypes may improve ventilation practice and outcome. However, additional research is warranted before personalized mechanical ventilation strategies can be applied at the bedside. Ventilatory parameters should be titrated based on close monitoring of targeted physiologic variables and individualized goals. Although low tidal volume (VT) is a standard of care, further individualization of VT may necessitate the evaluation of lung volume reserve (e.g., inspiratory capacity). Low driving pressures provide a target for clinicians to adjust VT and possibly to optimize positive end-expiratory pressure (PEEP), while maintaining plateau pressures below safety thresholds. Esophageal pressure monitoring allows estimation of transpulmonary pressure, but its use requires technical skill and correct physiologic interpretation for clinical application at the bedside. Mechanical power considers ventilatory parameters as a whole in the optimization of ventilation setting, but further studies are necessary to assess its clinical relevance. The identification of recruitability in patients with ARDS is essential to titrate and individualize PEEP. To define gas-exchange targets for individual patients, clinicians should consider issues related to oxygen transport and dead space. In this review, we discuss the rationale for personalized approaches to mechanical ventilation for patients with ARDS, the role of lung imaging, phenotype identification, physiologically based individualized approaches to ventilation, and a future research agenda.
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Affiliation(s)
- Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Carmen S V Barbas
- Pneumology and Intensive Care Medicine, University of São Paulo, São Paulo, Brazil
- Adult Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Unity Health Toronto-St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Sharon Einav
- Intensive Care Unit of the Shaare Zedek Medical Medical Centre, Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Luciano Gattinoni
- Department of Anaesthesiology, Emergency, and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, University Hospital Galway, and School of Medicine, National University of Ireland, Galway, Ireland
| | - John J Marini
- University of Minnesota and Regions Hospital, St. Paul, MN, USA
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marcus J Schultz
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jean Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, Inserm UMR S_999, AP-HP Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Scaramuzzo G, Spadaro S, Waldmann AD, Böhm SH, Ragazzi R, Marangoni E, Alvisi V, Spinelli E, Mauri T, Volta CA. Heterogeneity of regional inflection points from pressure-volume curves assessed by electrical impedance tomography. Crit Care 2019; 23:119. [PMID: 30992054 PMCID: PMC6469223 DOI: 10.1186/s13054-019-2417-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background The pressure-volume (P-V) curve has been suggested as a bedside tool to set mechanical ventilation; however, it reflects a global behavior of the lung without giving information on the regional mechanical properties. Regional P-V (PVr) curves derived from electrical impedance tomography (EIT) could provide valuable clinical information at bedside, being able to explore the regional mechanics of the lung. In the present study, we hypothesized that regional P-V curves would provide different information from those obtained from global P-V curves, both in terms of upper and lower inflection points. Therefore, we constructed pressure-volume curves for each pixel row from non-dependent to dependent lung regions of patients affected by acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS). Methods We analyzed slow-inflation P-V maneuvers data from 12 mechanically ventilated patients. During the inflation, the pneumotachograph was used to record flow and airway pressure while the EIT signals were recorded digitally. From each maneuver, global respiratory system P-V curve (PVg) and PVr curves were obtained, each one corresponding to a pixel row within the EIT image. PVg and PVr curves were fitted using a sigmoidal equation, and the upper (UIP) and lower (LIP) inflection points for each curve were mathematically identified; LIP and UIP from PVg were respectively called LIPg and UIPg. From each measurement, the highest regional LIP (LIPrMAX) and the lowest regional UIP (UIPrMIN) were identified and the pressure difference between those two points was defined as linear driving pressure (ΔPLIN). Results A significant difference (p < 0.001) was found between LIPrMAX (15.8 [9.2–21.1] cmH2O) and LIPg (2.9 [2.2–8.9] cmH2O); in all measurements, the LIPrMAX was higher than the corresponding LIPg. We found a significant difference (p < 0.005) between UIPrMIN (30.1 [23.5–37.6] cmH2O) and UIPg (40.5 [34.2–45] cmH2O), the UIPrMIN always being lower than the corresponding UIPg. Median ΔPLIN was 12.6 [7.4–20.8] cmH2O and in 56% of cases was < 14 cmH2O. Conclusions Regional inflection points derived by EIT show high variability reflecting lung heterogeneity. Regional P-V curves obtained by EIT could convey more sensitive information than global lung mechanics on the pressures within which all lung regions express linear compliance. Trial registration Clinicaltrials.gov, NCT02907840. Registered on 20 September 2016. Electronic supplementary material The online version of this article (10.1186/s13054-019-2417-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gaetano Scaramuzzo
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Azienda Ospedaliera - Universitaria Sant'Anna Hospital, Via Aldo Moro, Ferrara, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Azienda Ospedaliera - Universitaria Sant'Anna Hospital, Via Aldo Moro, Ferrara, Italy.
| | - Andreas D Waldmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Stephan H Böhm
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Azienda Ospedaliera - Universitaria Sant'Anna Hospital, Via Aldo Moro, Ferrara, Italy
| | - Elisabetta Marangoni
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Azienda Ospedaliera - Universitaria Sant'Anna Hospital, Via Aldo Moro, Ferrara, Italy
| | - Valentina Alvisi
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Azienda Ospedaliera - Universitaria Sant'Anna Hospital, Via Aldo Moro, Ferrara, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Ca' Granda, University of Milan, Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Ca' Granda, University of Milan, Milan, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Azienda Ospedaliera - Universitaria Sant'Anna Hospital, Via Aldo Moro, Ferrara, Italy
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