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McMenemy L, Behan FP, Kaufmann J, Cain D, Bennett AN, Boos CJ, Fear NT, Cullinan P, Bull AMJ, Phillips ATM, McGregor AH. Association Between Combat-Related Traumatic Injury and Skeletal Health: Bone Mineral Density Loss Is Localized and Correlates With Altered Loading in Amputees: the Armed Services Trauma Rehabilitation Outcome (ADVANCE) Study. J Bone Miner Res 2023; 38:1227-1233. [PMID: 37194399 DOI: 10.1002/jbmr.4794] [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: 10/28/2022] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 05/18/2023]
Abstract
The association between combat-related traumatic injury (CRTI) and bone health is uncertain. A disproportionate number of lower limb amputees from the Iraq and Afghanistan conflicts are diagnosed with osteopenia/osteoporosis, increasing lifetime risk of fragility fracture and challenging traditional osteoporosis treatment paradigms. The aim of this study is to test the hypotheses that CRTI results in a systemic reduction in bone mineral density (BMD) and that active traumatic lower limb amputees have localized BMD reduction, which is more prominent with higher level amputations. This is a cross-sectional analysis of the first phase of a cohort study comprising 575 male adult UK military personnel with CRTI (UK-Afghanistan War 2003 to 2014; including 153 lower limb amputees) who were frequency-matched to 562 uninjured men by age, service, rank, regiment, deployment period, and role-in-theatre. BMD was assessed using dual-energy X-ray absorptiometry (DXA) scanning of the hips and lumbar spine. Femoral neck BMD was lower in the CRTI than the uninjured group (T-score -0.08 versus -0.42 p = .000). Subgroup analysis revealed this reduction was significant only at the femoral neck of the amputated limb of amputees (p = 0.000), where the reduction was greater for above knee amputees than below knee amputees (p < 0.001). There were no differences in spine BMD or activity levels between amputees and controls. Changes in bone health in CRTI appear to be mechanically driven rather than systemic and are only evident in those with lower limb amputation. This may arise from altered joint and muscle loading creating a reduced mechanical stimulus to the femur resulting in localized unloading osteopenia. This suggests that interventions to stimulate bone may provide an effective management strategy. © 2023 Crown copyright and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.
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Affiliation(s)
- Louise McMenemy
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Institute of Naval Medicine, Gosport, UK
| | - Fearghal P Behan
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Josh Kaufmann
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
- Structural Biomechanics, Department of Civil and Environmental Engineering, Imperial College London, London, UK
- Musculoskeletal Biodynamics, Imperial College London, London, UK
| | - David Cain
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Christopher J Boos
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK
- Academic Department of Military Mental Health, King's College London, London, UK
- Faculty of Health & Social Sciences, Bournemouth University, Bournemouth, UK
- Cardiology, University Hospitals Dorset NHS Foundation Trust, Poole Hospital, Poole, UK
| | - Nicola T Fear
- Academic Department of Military Mental Health, King's College London, London, UK
| | - Paul Cullinan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Anthony M J Bull
- Centre for Blast Injury Studies, Department of Bioengineering, Imperial College London, London, UK
| | - Andrew T M Phillips
- Structural Biomechanics, Department of Civil and Environmental Engineering, Imperial College London, London, UK
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Zhu K, Hunter M, Stuckey BGA, Walsh JP. Establishing a Total Hip T-Score Threshold to Measure Contralateral Hip Bone Mineral Density: Avoiding Missed Diagnosis of Osteoporosis. J Clin Densitom 2022; 25:577-586. [PMID: 35606279 DOI: 10.1016/j.jocd.2022.04.003] [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: 12/23/2021] [Revised: 04/07/2022] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
Abstract
Bone mineral density (BMD) of the hip is routinely measured unilaterally, but can differ between left and right. This study aimed to establish total hip T-score thresholds for measuring contralateral hip BMD, to avoid missing the diagnosis of osteoporosis. In 4914 participants (2709 females) in the Busselton Healthy Ageing Study, BMD of both hips and lumbar spine (L1-L4) was measured by dual-energy x-ray absorptiometry (DXA) using a GE Lunar Prodigy Pro densitometer. Least significant change (LSC) was calculated according to International Society for Clinical Densitometry recommendations. For participants whose left-right total hip BMD difference exceeded LSC, the 95th percentile of the difference in T-score was calculated, then added to -2.5 (the cut-off for osteoporosis) to derive T-score thresholds for measuring contralateral hip to avoid a missed diagnosis in 95% of individuals. Participant mean age (±SD) was 57.4 ± 5.8 years; total hip T-score was 0.7 ± 0.1 in males and -0.2 ± 1.1 in females. Left and right total hip BMD were highly correlated (r = 0.943 for males, 0.959 for females), but in 56.2% of males and 50.0% of females, the left-right difference exceeded the LSC of 0.026 g/cm2. In these participants, the 95th percentile of difference in T-score between two hips was 0.872 in males and 0.742 in females. This gave T-score thresholds for measuring contralateral total hip BMD of -1.6 (males) and -1.8 (females). When total hip T-score is between -1.6 and -2.5 (males), or between -1.8 and -2.5 (females), measuring contralateral hip BMD could avoid a missed diagnosis of osteoporosis.
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Affiliation(s)
- Kun Zhu
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Medical School, University of Western Australia, Crawley, Western Australia, Australia.
| | - Michael Hunter
- School of Population and Global Health, University of Western Australia, Crawley, Western Australia, Australia; Busselton Population Medical Research Institute, Busselton, Western Australia, Australia
| | - Bronwyn G A Stuckey
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Medical School, University of Western Australia, Crawley, Western Australia, Australia; Keogh Institute for Medical Research, Nedlands, Western Australia, Australia
| | - John P Walsh
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Medical School, University of Western Australia, Crawley, Western Australia, Australia
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Sergio RO, Nayelli RGE. Evaluation of the bone mineral density in the Mexican female population using the Radiofrequency Echographic Multi Spectrometry (REMS) technology. Arch Osteoporos 2022; 17:43. [PMID: 35257242 DOI: 10.1007/s11657-022-01080-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/15/2022] [Indexed: 02/03/2023]
Abstract
The bone health status of a Mexican female population, including a cohort of 455 women aged over 40 years, was assessed by Radiofrequency Echographic Multi Spectrometry (REMS). PURPOSE Assessment of the bone health status in an average female Mexican population with REMS. The secondary objective investigated age- and body mass index (BMI)-related effects on the diagnostic classification and the influence of risk factors for osteoporosis. METHODS Women aged over 40 years underwent a REMS scan at the lumbar spine and both femoral necks. The degree of correlation of the bone mineral density (BMD) across axial sites was assessed by the Pearson correlation coefficient (r), along with the diagnostic discordance. The association between risk factors, age, and BMI and diagnostic classification was determined by the chi-squared test. RESULTS Four hundred seventy-one women were enrolled. Osteoporosis was diagnosed in 11.0%, 8.1%, and 8.3% of cases at the lumbar spine and right and left femoral neck, respectively. The diagnostic agreement between the lumbar spine and femoral necks was about 73% (85% considering a 0.3 T-score tolerance), whereas the agreement between the femoral necks was 97.4% (99.6% considering a 0.3 T-score tolerance). Most of discordant cases were minor discordances. The correlation between the lumbar spine and femoral neck was r = 0.82 and 0.85, respectively, whereas both femoral necks correlated with r = 0.97. As expected, the prevalence of osteoporosis increased with age and decreased as BMI increased. CONCLUSION The widespread applicability of the non-ionizing REMS technology has been demonstrated in a representative Mexican cohort, covering wide age and BMI ranges. Age and BMI variations correlate with the prevalence of osteoporosis, in line with the recent scientific literature.
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Affiliation(s)
- Rosales-Ortiz Sergio
- Hospital de Gineco Obstetricia, No. 4 "Luis Castelazo Ayala", IMSS, Mexico City, Mexico.
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Kaushal N, Vohora D, Jalali RK, Jha S. Prevalence of osteoporosis and osteopenia in an apparently healthy Indian population - a cross-sectional retrospective study. Osteoporos Sarcopenia 2018; 4:53-60. [PMID: 30775543 PMCID: PMC6362954 DOI: 10.1016/j.afos.2018.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 03/08/2018] [Accepted: 04/26/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES An understanding of bone mineral density (BMD) pattern in a population is crucial for prevention and diagnosis of osteoporosis and management of its complications in later life. This study aimed to screen the bone health status and factors associated with osteoporosis in an apparently healthy Indian population. METHODS A retrospective review of medical records was done in a tertiary-care hospital for the subjects who had undergone preventive health-check-ups that included BMD measurements at femur-neck, total-femur, and lumbar-spine. RESULTS We evaluated 524 subjects (age, 50.0 ± 12.4 years) including 41.2% female and 58.8% male subjects. Osteoporosis was present in 6.9% subjects (female, 11.1%; male, 4.2%) and osteopenia in 34% subjects (female, 40.3%; male, 29.9%). Absolute BMD was higher in male subjects (P < 0.001) compared to female subjects at all bone sites. Prevalence of osteoporosis increased with age in female subjects, but not in male subjects. Osteoporosis rates in the age-groups of 30-39, 40-49, 50-59, 60-69, and ≥70 years were 3%, 3.4%, 14.3%, 18.6%, and 36.4%, respectively in female subjects while prevalence in male subjects was 0%, 4%, 6.5%, 4.3%, and 5.6%, respectively, at lumbar spine. Height (r = 0.234-0.358), weight (r = 0.305-0.388), body mass index (r = 0.143-0.285) and physical activity (r = 0.136-0.153) were positively; and alkaline phosphatase (r = -0.133 to -0.203) was negatively correlated with BMD (all P < 0.01) at all sites. These parameters retained significant correlation after controlling for age and sex. No correlation of serum 25-hydroxy-vitamin-D and calcium was noted with BMD (P > 0.05) at any site. CONCLUSIONS Further data on absolute BMD, T scores, and prevalence rates of osteoporosis/osteopenia on multiple bone sites have been presented in this article.
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Affiliation(s)
- Neelam Kaushal
- Pharmaceutical Medicine, Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Divya Vohora
- Pharmaceutical Medicine, Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Rajinder K. Jalali
- Medical Affairs & Clinical Research, Sun Pharmaceutical Industries Limited, Gurgaon, India
| | - Sujeet Jha
- Institute of Endocrinology, Diabetes and Metabolism, Max Healthcare Inst. Ltd., New Delhi, India
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Faisal TR, Luo Y. Study of the variations of fall induced hip fracture risk between right and left femurs using CT-based FEA. Biomed Eng Online 2017; 16:116. [PMID: 28974207 PMCID: PMC5627442 DOI: 10.1186/s12938-017-0407-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 09/22/2017] [Indexed: 01/23/2023] Open
Abstract
Background Hip fracture of elderly people—suffering from osteoporosis—is a severe public health concern, which can be reduced by providing a prior assessment of hip fracture risk. Image-based finite element analysis (FEA) has been considered an effective computational tool to assess the hip fracture risk. Considering the femoral neck region is the weakest, fracture risk indicators (FRI) are evaluated for both single-legged stance and sideways fall configurations and are compared between left and right femurs of each subject. Quantitative Computed Tomography (QCT) scan datasets of thirty anonymous patients’ left and right femora have been considered for the FE models, which have been simulated with an equal magnitude of load applied to the aforementioned configurations. The requirement of bilateral hip assessment in predicting the fracture risk has been explored in this study. Results Comparing the sideways fall and single-legged stance, the FRI varies by 64 to 74% at the superior aspects and by 14 to 19% at the inferior surfaces of both the femora. The results of this in vivo analysis clearly substantiate that the fracture is expected to initiate at the superior surface of femoral neck region if a patient falls from his/her standing height. The distributions of FRI between the femurs vary considerably, and the variability is significant at the superior aspects. The p value (= 0.02) obtained from paired sample t-Test yields p value ≤ 0.05, which shows the evidence of variability of the FRI distribution between left and right femurs. Moreover, the comparison of FRIs between the left and right femur of men and women shows that women are more susceptible to hip fracture than men. Conclusions The results and statistical variation clearly signify a need for bilateral hip scanning in predicting hip fracture risk, which is clinically conducted, at present, based on one hip chosen randomly and may lead to inaccurate fracture prediction. This study, although preliminary, may play a crucial role in assessing the hip fractures of the geriatric population and thereby, reducing the cost of treatment by taking predictive measure.
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Affiliation(s)
- Tanvir R Faisal
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA.,Legs + Walking Lab, Shirley Ryan AbilityLab, Chicago, IL, 60610, USA
| | - Yunhua Luo
- Department of Mechanical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, R3T 2N2, Canada.
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Brozgol M, Arbiv M, Mirelman A, Herman T, Hausdorff JM, Vaisman N. Vertical ground reaction force during standing and walking: Are they related to bone mineral density left-right asymmetries? Gait Posture 2017; 54:174-177. [PMID: 28324752 DOI: 10.1016/j.gaitpost.2017.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/02/2017] [Accepted: 03/06/2017] [Indexed: 02/02/2023]
Abstract
Osteoporosis is a systemic skeletal disease that is characterized by reduced bone mass, deterioration of bone tissue and skeletal fragility. The purpose of the current study was to determine whether asymmetrical femur bone mineral density (BMD) is associated with asymmetrical gait and standing. We compared measures of gait and standing asymmetry in subjects with (n=38) and without (n=11) significant left-right differences in BMD. Participants walked for 72m at their comfortable speed and stood quietly for 60s while outfitted with pressure-sensitive insoles. Based on the pressure measurements, indices of standing and gait asymmetry were determined. Gait Asymmetry (GA) indices of maximum ground reaction force (GRF) and stance time were significantly higher in the asymmetrical BMD group, compared to the symmetrical group (p<0.03). During quiet standing, maximal GRF was twice as high in those with BMD asymmetry, compared to those without, although this difference was not statistically significant (p=0.10). These preliminary findings indicate that femur BMD asymmetry and gait asymmetry are interrelated in otherwise healthy adults. Nutrition, metabolism and lifestyle are known contributors to BMD; typically, they affect bone health symmetrically. We suggest, therefore, that the BMD asymmetry may be due to previous changes in the loading pattern during walking that might have led to asymmetric bone deterioration. Future larger scale and prospective studies are needed to identify the mechanisms underlying the relationship between standing, gait and BMD and to explore whether gait training and exercises that target gait symmetry might help to reduce BMD asymmetry.
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Affiliation(s)
- Marina Brozgol
- Center for the study of Movement, Cognition and Mobility, Tel Aviv Sourasky Medical Center, Israel.
| | - Mira Arbiv
- Unit of Clinical Nutrition, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anat Mirelman
- Center for the study of Movement, Cognition and Mobility, Tel Aviv Sourasky Medical Center, Israel; Department of Neurology, Sackler School of Medicine, Tel Aviv University, Israel
| | - Talia Herman
- Center for the study of Movement, Cognition and Mobility, Tel Aviv Sourasky Medical Center, Israel
| | - Jeffrey M Hausdorff
- Center for the study of Movement, Cognition and Mobility, Tel Aviv Sourasky Medical Center, Israel; Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel; Department of Physical Therapy, Sackler School of Medicine, Tel Aviv University, Israel
| | - Nachum Vaisman
- Unit of Clinical Nutrition, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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FRAX fracture risk in women with a recent fracture of the distal forearm: agreement between assessments with and without bone mineral density and impact of measurement side in the individual patient. Clin Rheumatol 2014; 34:1265-72. [DOI: 10.1007/s10067-014-2640-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 04/17/2014] [Indexed: 01/19/2023]
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Kim S, Yang KH, Lim H, Lee YK, Yoon HK, Oh CW, Park KK, Min BW, Ryu JA, Kwack KS, Lee YH. Detection of prefracture hip lesions in atypical subtrochanteric fracture with dual-energy x-ray absorptiometry images. Radiology 2013; 270:487-95. [PMID: 24126368 DOI: 10.1148/radiol.13122691] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively assess how often and how early hip dual-energy x-ray absorptiometry (DXA) images show prefracture lesions in patients with atypical subtrochanteric fracture (ASF) and determine whether DXA images with assessment of prodromal symptoms could be used for early ASF prediction. MATERIALS AND METHODS The retrospective research protocol complied with HIPAA and was institutional review board approved, with waiver of informed consent. Among 62 women with ASF, nine without hip DXA images and seven without clear documentation of prodromal symptoms were excluded. Serial DXA images of 52 hips in 46 patients were included. Among them, 33 hips were assessed with ipsilateral DXA. For this ipsilateral group, each hip was assessed for prodromal symptoms and focal cortical changes in the lateral subtrochanteric femur cortex at DXA. Overall and cumulative detection rates for prodromal symptoms, DXA, and DXA with prodromal symptoms were measured and compared with a general linear model for overall detection rate and Cox proportional hazard models for cumulative detection rate. Thirty-three representative ipsilateral images and 199 images from subjects without fractures were reviewed in random order for prefracture lesions by three musculoskeletal radiologists independently, and the performance of DXA in ASF prediction was assessed. RESULTS Overall detection rates for DXA, prodromal symptoms, and DXA with prodromal symptoms were 61% (20 of 33), 42% (14 of 33), and 73% (24 of 33), respectively, in the ipsilateral group. Overall detection rate comparisons showed that DXA with prodromal symptoms was superior to prodromal symptoms alone (P = .0377). The cumulative detection rate curve for DXA with prodromal symptoms was also superior to that of prodromal symptoms alone (P = .0018). Sensitivity and specificity of DXA in ASF prediction ranged from 52% (17 of 33) to 58% (19 of 33) and 99% (197 of 199) to 100% (199 of 199), respectively. CONCLUSION Assessment of hip DXA images combined with conventional assessment of prodromal symptoms enables detection of more ASFs earlier than assessment based on prodromal symptoms alone.
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Affiliation(s)
- Sungjun Kim
- From the Depts of Radiology (S.K.) and Orthopedic Surgery (K.H.Y.), Gangnam Severance Hosp, Yonsei Univ College of Medicine, 211 Eonju-ro, Gangnam-Gu, Seoul 135-720, South Korea; Biostatistics Collaboration Unit, Gangnam Severance Hosp, Biomedical Research Ctr, Yonsei Univ College of Medicine, Seoul, South Korea (H.L.); Dept of Orthopedic Surgery, Seoul National Univ Bundang Hosp, Sungnam-si, South Korea (Y.K.L.); Dept of Orthopedic Surgery, National Health Insurance Corporation Ilsan Hosp, Goyang, South Korea (H.K.Y.); Dept of Orthopedic Surgery, Kyungpook National Univ Hosp, Daegu, South Korea (C.W.O.); Depts of Orthopedic Surgery (K.K.P.) and Radiology (Y.H.L.), Severence Hospital, Yonsei University College of Medicine, Seoul, South Korea; Dept of Orthopedic Surgery, Keimyung Univ Dongsan Medical Ctr, Daegu, South Korea (B.W.M.); Dept of Radiology, Hanyang Univ Guri Hosp, Hanyang Univ, Guri, South Korea (J.A.R.); and Dept of Radiology, Ajou Univ Hosp, Ajou Univ School of Medicine, Uwon, South Korea (K.S.K.)
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