1
|
Pruitt P, Castillo R, Rogers A, Prabhakaran S, Muschong K, Scudder M, McCarthy DM, Holl JL, Courtney DM, Borczuk P, Naidech A. External Validation of a Tool to Identify Low-Risk Patients With Isolated Subdural Hematoma and Preserved Consciousness. Ann Emerg Med 2024; 83:421-431. [PMID: 37725019 DOI: 10.1016/j.annemergmed.2023.08.481] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 06/29/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023]
Abstract
STUDY OBJECTIVE The SafeSDH Tool was derived to identify patients with isolated (no other type of intracranial hemorrhage) subdural hematoma who are at very low risk of neurologic deterioration, neurosurgical intervention, or death. Patients are low risk by the tool if they have none of the following: use of anticoagulant or nonaspirin antiplatelet agent, Glasgow Coma Score (GCS) <14, more than 1 discrete hematoma, hematoma thickness >5 mm, or midline shift. We attempted to externally validate the SafeSDH Tool. METHODS We performed a retrospective chart review of patients aged ≥16 with a GCS ≥13 and isolated subdural hematoma who presented to 1 of 6 academic and community hospitals from 2005 to 2018. The primary outcome, a composite of neurologic deterioration (seizure, altered mental status, or symptoms requiring repeat imaging), neurosurgical intervention, discharge on hospice, and death, was abstracted from discharge summaries. Hematoma thickness, number of hematomas, and midline shift were abstracted from head imaging reports. Anticoagulant use, antiplatelet use, and GCS were gathered from the admission record. RESULTS The validation data set included 753 patients with isolated subdural hematoma. Mortality during the index admission was 2.1%; 26% of patients underwent neurosurgical intervention. For the composite outcome, sensitivity was 99% (95% confidence interval [CI] 97 to 100), and specificity was 31% (95% CI 27 to 35). The tool identified 162 (21.5%) patients as low risk. Negative likelihood ratio was 0.03 (95% CI 0.01 to 0.11). CONCLUSION The SafeSDH Tool identified patients with isolated subdural hematoma who are at low risk for poor outcomes with high sensitivity. With prospective validation, these low-risk patients could be safe for management in less intensive settings.
Collapse
Affiliation(s)
- Peter Pruitt
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Richmond Castillo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Andrew Rogers
- Department of Emergency Medicine, North Shore Health System, Evanston, IL
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Kayla Muschong
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael Scudder
- New York University Grossman School of Medicine, New York, NY
| | - Danielle M McCarthy
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jane L Holl
- Department of Neurology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Andrew Naidech
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
2
|
Yue JK, Krishnan N, Kanter JH, Deng H, Okonkwo DO, Puccio AM, Madhok DY, Belton PJ, Lindquist BE, Satris GG, Lee YM, Umbach G, Duhaime AC, Mukherjee P, Yuh EL, Valadka AB, DiGiorgio AM, Tarapore PE, Huang MC, Manley GT, Investigators TTRACKTBI. Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study. J Clin Med 2023; 12:2024. [PMID: 36902811 PMCID: PMC10004432 DOI: 10.3390/jcm12052024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization. METHODS Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported. RESULTS In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]). CONCLUSIONS Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.
Collapse
Affiliation(s)
- John K. Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Nishanth Krishnan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - John H. Kanter
- Section of Neurological Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Debbie Y. Madhok
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA 94110, USA
| | - Patrick J. Belton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Britta E. Lindquist
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA 94110, USA
| | - Gabriela G. Satris
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Young M. Lee
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Gray Umbach
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Ann-Christine Duhaime
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94110, USA
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94110, USA
| | - Alex B. Valadka
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA 94158, USA
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Michael C. Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | | |
Collapse
|
3
|
Orlando A, Coresh J, Carrick MM, Quan G, Berg GM, Dhakal L, Hamilton D, Madayag R, Lascano CHP, Bar-Or D. Characterizing Interhospital Variability in Neurosurgical Interventions for Patients with Mild Traumatic Brain Injury and Intracranial Hemorrhage. Neurotrauma Rep 2023; 4:149-158. [PMID: 36941879 PMCID: PMC10024575 DOI: 10.1089/neur.2022.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
The objective of this study was to quantify nation-wide interhospital variation in neurosurgical intervention risk by intracranial hemorrhage (ICH) type in the setting of mild traumatic brain injury (mTBI). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the National Trauma Data Bank from 2007 to 2019 with an emergency department Glasgow Coma Scale score 13-15, diagnosed ICH, no skull fracture. The primary outcome was neurosurgical intervention. Interhospital variation was assessed by examining the best linear unbiased predictors (BLUPs) obtained from mixed-effects logistic regression with random slopes and intercepts for hospitals and covariates for time and 14 demographic, injury, and hospital characteristics; one model per ICH type. Intercept BLUPs are estimates of how different each hospital is from the average hospital (after covariate adjustment). The study population included 49,220 (7%) neurosurgical interventions among 666,842 patients in 1060 hospitals. In 2019, after adjusting for patient case-mix and hospital characteristics, the percentage of hospitals with hemorrhage-specific neurosurgical intervention risk significantly different from the average hospital was as follows: isolated unspecified hemorrhage (0% of 995 hospitals); isolated contusion/laceration (0.54% of 929); isolated epidural hemorrhage (0.39% of 778); isolated subarachnoid hemorrhage (0.10% of 1002); multiple hemorrhages (2.49% of 963); and isolated subdural hemorrhage (16.25% of 1028). In the setting of mTBI, isolated subdural hemorrhages were the only ICH type to have considerable interhospital variability. Causes for this significant variation should be elucidated and might include changing hemorrhage characteristics and practice patterns over time.
Collapse
Affiliation(s)
- Alessandro Orlando
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Address correspondence to: Alessandro Orlando, PhD, MPH, Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, 501 E. Hampden Avenue, Englewood, CO 80113, USA
| | - Josef Coresh
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Glenda Quan
- Department of Trauma Services, Swedish Medical Center, Englewood, Colorado, USA
| | - Gina M. Berg
- Department of Trauma Services, Wesley Medical Center, Wichita, Kansas, USA
| | - Laxmi Dhakal
- Department of Trauma Services, Wesley Medical Center, Wichita, Kansas, USA
| | - David Hamilton
- Department of Trauma Services, Penrose Hospital, Colorado Springs, Colorado, USA
| | - Robert Madayag
- Department of Trauma Services, St. Anthony Hospital, Lakewood, Colorado, USA
| | | | - David Bar-Or
- Injury Outcomes Network, Englewood, Colorado, USA
| |
Collapse
|
4
|
Orlando A, Coresh J, Carrick MM, Quan G, Berg GM, Dhakal L, Hamilton D, Madayag R, Lascano CHP, Bar-Or D. Significant National Declines in Neurosurgical Intervention for Mild Traumatic Brain Injury with Intracranial Hemorrhage: A 13-Year Review of the National Trauma Data Bank. Neurotrauma Rep 2023; 4:137-148. [PMID: 36941880 PMCID: PMC10024583 DOI: 10.1089/neur.2022.0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
There have been large changes over the past several decades to patient demographics in those presenting with mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH; complicated mTBI) with the potential to affect the use of neurosurgical interventions. The objective of this study was to characterize long-term trends of neurosurgical interventions in patients with complicated mTBI using 13 years of the National Trauma Data Bank (NTDB). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the NTDB from 2007 to 2019 who had an emergency department Glasgow Coma Scale score 13-15, an intracranial hemorrhage (ICH), and no skull fracture. Neurosurgical intervention time trends were quantified for each ICH type using mixed-effects logistic regression with random slopes and intercepts for hospitals, as well as covariates for time and 14 demographic, injury, and hospital characteristics. In total, 666,842 ICH patients across 1060 hospitals were included. The four most common hemorrhages were isolated subdural hemorrhage (36%), isolated subarachnoid hemorrhage (24%), multiple hemorrhage types (24%), and isolated unspecified hemorrhages (9%). Overall, 49,220 (7%) patients received a neurosurgical intervention. After adjustment, the odds of neurosurgical intervention significantly decreased every 10 years by the following odds ratios (odds ratio [95% confidence interval]): 0.85 [0.78, 0.93] for isolated subdural, 0.63 [0.51, 0.77] for isolated subarachnoid, 0.50 [0.41, 0.62] for isolated unspecified, and 0.79 [0.73, 0.86] for multiple hemorrhages. There were no significant temporal trends in neurosurgical intervention odds for isolated epidural hemorrhages (0.87 [0.68, 1.12]) or isolated contusions/lacerations (1.03 [0.75, 1.41]). In the setting of complicated mTBI, the four most common ICH types were associated with significant declines in the odds of neurosurgical intervention over the past decade. It remains unclear whether changing hemorrhage characteristics or practice patterns drove these trends.
Collapse
Affiliation(s)
- Alessandro Orlando
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Address correspondence to: Alessandro Orlando, PhD, MPH, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 501 E. Hampden Avenue, Englewood, CO 80443, USA;
| | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Glenda Quan
- Swedish Medical Center, Englewood, Colorado, USA
| | | | | | | | | | | | - David Bar-Or
- Medical City Plano, Plano, Texas, USA
- Swedish Medical Center, Englewood, Colorado, USA
- Wesley Medical Center, Wichita, Kansas, USA
- Penrose Hospital, Colorado Springs, Colorado, USA
- St. Anthony Hospital, Lakewood, Colorado, USA
- South Texas Health System McAllen, McAllen, Texas, USA
| |
Collapse
|
5
|
Pruitt P, Naidech A, Van Ornam J, Borczuk P, Thompson W. A natural language processing algorithm to extract characteristics of subdural hematoma from head CT reports. Emerg Radiol 2019; 26:301-306. [PMID: 30693414 DOI: 10.1007/s10140-019-01673-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage, and radiographic characteristics of SDH are predictive of complications and patient outcomes. We created a natural language processing (NLP) algorithm to extract structured data from cranial computed tomography (CT) scan reports for patients with SDH. METHODS CT scan reports from patients with SDH were collected from a single center. All reports were based on cranial CT scan interpretations by board-certified attending radiologists. Reports were then coded by a pair of physicians for four variables: number of SDH, size of midline shift, thickness of largest SDH, and side of largest SDH. Inter-rater reliability was assessed. The annotated reports were divided into training (80%) and test (20%) datasets. Relevant information was extracted from text using a pattern-matching approach, due to the lack of a mention-level gold-standard corpus. Then, the NLP pipeline components were integrated using the Apache Unstructured Information Management Architecture. Output performance was measured as algorithm accuracy compared to the data coded by the two ED physicians. RESULTS A total of 643 scans were extracted. The NLP algorithm accuracy was high: 0.84 for side of largest SDH, 0.88 for thickness of largest SDH, and 0.92 for size of midline shift. CONCLUSION A NLP algorithm can structure key data from non-contrast head CT reports with high accuracy. The NLP is a potential tool to detect important radiographic findings from electronic health records, and, potentially, add decision support capabilities.
Collapse
Affiliation(s)
- Peter Pruitt
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, 633 N St. Clair Street, Chicago, IL, 60622, USA.
| | - Andrew Naidech
- Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, 633 N St. Clair Street, Chicago, IL, 60622, USA.,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jonathan Van Ornam
- Harvard Affiliated Emergency Medicine Residency, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Pierre Borczuk
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - William Thompson
- Center for Health Information Partnerships, Northwestern University Feinberg School of Medicine, 625 N Michigan Ave., Chicago, IL, 60611, USA
| |
Collapse
|
6
|
Chmieliauskas S, Anuzyte JS, Liucvaikyte J, Laima S, Jurolaic E, Rocka S, Fomin D, Stasiuniene J, Jasulaitis A. Importance of effusion of blood under the dura mater in forensic medicine: A STROBE - compliant retrospective study. Medicine (Baltimore) 2018; 97:e12567. [PMID: 30278562 PMCID: PMC6181611 DOI: 10.1097/md.0000000000012567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Subdural hemorrhage is commonly associated with mechanical brain injury and has a correspondingly high mortality rate. Subdural hematomas may immediately provoke symptoms or may be initially asymptomatic, with further symptoms evolving rapidly and fatally.The data regarding forensic autopsy of victims were obtained from The State Forensic Medicine Service of Lithuania between the years 2013 and 2016. A retrospective study was performed including 110 patients, whose cause of death was subdural hemorrhage. 95% confidence intervals were calculated.It was calculated, that in cases of sudden death, after subdural hemorrhage was diagnosed, a higher concentration of ethyl alcohol in blood (mean 2.22 ± 1.3%) demanded a smaller amount of blood under the dura matter (mean 81.6 ± 60.5 g) in order for the patient to die. It was also noted that hospitalized patients with subdural hemorrhage had a smaller concentration of blood ethyl alcohol (mean 1.33 ± 1%) and a larger amount of blood under the dura (mean 135.6 ± 82.9 g).Due to the toxic effect of ethyl alcohol, even a small amount (81.6 ± 60.5 g) of blood under the dura matter can determine a sudden death.
Collapse
Affiliation(s)
- Sigitas Chmieliauskas
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
- State Forensic Medicine Service
| | - Joginte Saule Anuzyte
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| | - Julita Liucvaikyte
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| | - Sigitas Laima
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
- State Forensic Medicine Service
| | | | - Saulius Rocka
- Department of Neurology and Neurosurgery, Vilnius University, Vilnius, Lithuania
| | - Dmitrij Fomin
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
- State Forensic Medicine Service
| | - Jurgita Stasiuniene
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| | - Algimantas Jasulaitis
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| |
Collapse
|