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Ignatov PN, Neykova KK, Yordanova-Ignatova T. Diastolic deceleration area in the fetal MCA: a new Doppler parameter. J Matern Fetal Neonatal Med 2023; 36:2206939. [PMID: 37121906 DOI: 10.1080/14767058.2023.2206939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Objective: Doppler velocimetry has been widely used throughout the years as a valuable tool in the follow-up and prognosis of various pregnancy complications. Numerous Doppler indices have been introduced to qualitatively describe fetal blood flow. Currently, the Pulsatility index (PI) is the most widely used index for this purpose. In current clinical practice, middle cerebral artery (MCA) PI measurement is commonly used to assess fetal well-being, especially in late-onset fetal growth restriction (FGR). However, existing evidence suggests that MCA PI alone is inferior to the ratio between MCA and umbilical artery (UA) pulsatility indices in predicting adverse perinatal and neonatal outcomes. When comparing normal and abnormal MCA Doppler waveforms, it is evident that most changes appear in the diastolic part of the heart cycle. Therefore, the PI, which contains elements from both systole (peak systolic velocity-PSV) and diastole (end-diastolic velocity), may not be the most effective tool for quantifying fetal brain sparing (BS).Methods: We hypothesize that another measurement modality that focuses predominantly on the diastole could be more efficient for evaluating the amount of vasodilatation. In ultrasound velocimetry of larger blood vessels, there is a well-known phenomenon called "dicrotic notch" (DN), which appears on the declining part of each Doppler waveform and can be used to precisely pinpoint the end of systole and the start of diastole. We hypothesized that the extent of cerebral vasodilation can be more accurately assessed by measuring the area between the dicrotic notch (DN) and the end-diastolic velocity (which we refer to as the "diastolic deceleration area-DDA"). In this study, we introduced a new Doppler parameter along with a rationale for DDA measurement in the fetal MCA. We also defined third-trimester nomograms and provided a preliminary assessment of the correlation between DDA and fetal oxygen deficiency.Results: Our findings suggest that the DDA may serve as an independent instrument for identifying hypoxia during late pregnancy, either on its own or in conjunction with other Doppler and cardiotocography modalities.Conclusion: However, before incorporating DDA into clinical practice, it is crucial to conduct further research and validation studies with larger sample sizes and more diverse populations. This would help assess the generalizability of the results and establish optimal cutoff points for DDA in various clinical settings. It is also important to prospectively study the role of DDA in early- and late-onset fetal growth restriction (FGR), Rh-isoimmunization/anemia, preeclampsia, gestational diabetes, and other pregnancy complications. In fact, we believe that the concept of measuring specific areas in arterial Doppler velocimetry indices could have significant implications not only in fetal medicine and obstetrics, but also in other areas of human and veterinary medicine.
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Affiliation(s)
- P N Ignatov
- Department of Public Health, Medical University of Sofia, Sofia, Bulgaria
- Department of Fetal Medicine, Orthogyn Medical Center, Sofia, Bulgaria
| | - K K Neykova
- Department of High-Risk Pregnancy, State University Hospital "Maichin dom", Sofia, Bulgaria
| | - T Yordanova-Ignatova
- Department of Fetal Medicine, Orthogyn Medical Center, Sofia, Bulgaria
- Department of Social Medicine, Medical University of Sofia, Sofia, Bulgaria
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Abushouk A, Kansara T, Abdelfattah O, Badwan O, Hariri E, Chaudhury P, Kapadia SR. The Dicrotic Notch: Mechanisms, Characteristics, and Clinical Correlations. Curr Cardiol Rep 2023; 25:807-816. [PMID: 37493873 DOI: 10.1007/s11886-023-01901-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE OF REVIEW The dicrotic notch (DN) has long been considered a marker of arterial stiffness and compliance. Herein, we explored the recent developments in vascular medicine research in an attempt to assess the DN utility in clinical cardiovascular medicine. RECENT FINDINGS Since its discovery, several studies have attempted to measure the changes in different parameters of the DN in physiological and pathological states. Despite the significance of their findings, the clinical role of the DN remained limited. This may have been related to the difficulty of measuring the DN via indwelling arterial catheters in the past. However, over the past two decades, several non-invasive methods have been developed, which may re-ignite interest in DN research. The DN may have broader applications in clinical cardiovascular medicine. Further research is needed to establish the accuracy of DN non-invasive measurement methods and compare its prognostic value to other circulatory parameters.
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Affiliation(s)
- Abdelrahman Abushouk
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tikal Kansara
- Department of Hospital Medicine, Union Hospital, Cleveland Clinic Foundation, Dover, OH, USA
| | - Omar Abdelfattah
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Essa Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
- Division of Cardiovascular Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Pulkit Chaudhury
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA.
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van den Bos-van de Steeg MGM, Fekkes S, Saris AECM, de Korte CL, Hansen HHG. In Vivo Comparison of Pulse Wave Velocity Estimation Based on Ultrafast Plane Wave Imaging and High-Frame-Rate Focused Transmissions. Ultrasound Med Biol 2022; 48:2335-2343. [PMID: 35999121 DOI: 10.1016/j.ultrasmedbio.2022.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/16/2022] [Accepted: 06/03/2022] [Indexed: 06/15/2023]
Abstract
Ultrasound-based local pulse wave velocity (PWV) estimation, as a measure of arterial stiffness, can be based on fast focused imaging (FFI) or plane wave imaging (PWI). This study was aimed at comparing the accuracy of in vivo PWV estimation using FFI and PWI. Ultrasound radiofrequency data of carotid arteries were acquired in 14 healthy volunteers (25-57 y) by executing the FFI (12 lines, 7200 Hz) and PWI (128 lines, 2000 Hz) methods consecutively. PWV was derived at two time-reference points, dicrotic notch (DN) and systolic foot (SF), for multiple pressure cycles by fitting a linear function through the positions of the peaks of low-pass filtered wall acceleration curves as a function of time. The accuracy of PWV estimation was determined for various cutoff frequencies (10-200 Hz). No statistically significant difference was observed between PWVs estimated by both approaches. The PWV and R2 at DN were higher, on average, than those at SF (PWV/R2: FFI SF 5.5/0.92, FFI DN 6.1/0.92; PWI SF 5.4/0.89, PWI DN 6.3/0.95). The use of cutoff frequencies between 40 and 80 Hz provided the most accurate PWVs. Both methods seemed equally suitable for use in clinical practice, although we have a preference for the PWV at DN given the higher R2 values.
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Affiliation(s)
- Melissa G M van den Bos-van de Steeg
- Department of Medical Imaging, Medical Ultrasound Imaging Center, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Medical Physics, Catharina Hospital, Eindhoven, The Netherlands
| | - Stein Fekkes
- Department of Medical Imaging, Medical Ultrasound Imaging Center, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anne E C M Saris
- Department of Medical Imaging, Medical Ultrasound Imaging Center, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chris L de Korte
- Department of Medical Imaging, Medical Ultrasound Imaging Center, Radboud University Medical Center, Nijmegen, The Netherlands; Physics of Fluid Group, TechMed Centrum, University of Twente, Enschede, The Netherlands.
| | - Hendrik H G Hansen
- Department of Medical Imaging, Medical Ultrasound Imaging Center, Radboud University Medical Center, Nijmegen, The Netherlands
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4
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Kemper PPN, Mahmoudi S, Apostolakis IZ, Konofagou EE. Feasibility of Bilinear Mechanical Characterization of the Abdominal Aorta in a Hypertensive Mouse Model. Ultrasound Med Biol 2021; 47:3480-3490. [PMID: 34507874 PMCID: PMC8693438 DOI: 10.1016/j.ultrasmedbio.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 07/28/2021] [Accepted: 08/01/2021] [Indexed: 05/19/2023]
Abstract
A change in elastin and collagen content is indicative of damage caused by hypertension, which changes the non-linear behavior of the vessel wall. This study was aimed at investigating the feasibility of monitoring the non-linear material behavior in an angiotensin II hypertensive mice model. Aortas from 13 hypertensive mice were imaged with pulse wave imaging (PWI) over 4 wk using a 40-MHz linear array. The pulse wave velocity was estimated using two wave features: (i) the maximum axial acceleration of the foot (PWVdia) and (ii) the maximum axial acceleration of the dicrotic notch (PWVend-sys). The Bramwell-Hill equation was used to derive the compliance at diastolic and end-systolic pressure. This study determined the potential of PWI in a hypertensive mouse model to image and quantify the non-linear material behavior in vivo. End-systolic compliance could differentiate between the sham and angiotensin II groups, whereas diastolic compliance could not, indicating that PWI can detect early collagen-dominated remodeling.
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Affiliation(s)
- Paul P N Kemper
- Ultrasound and Elasticity Imaging Laboratory, Department of Biomedical Engineering, Columbia University, New York, New York, USA.
| | - Salah Mahmoudi
- Ultrasound and Elasticity Imaging Laboratory, Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Iason Zacharias Apostolakis
- Ultrasound and Elasticity Imaging Laboratory, Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Elisa E Konofagou
- Ultrasound and Elasticity Imaging Laboratory, Department of Biomedical Engineering, Columbia University, New York, New York, USA; Department of Radiology, Columbia University, New York, New York, USA
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Balmer J, Smith R, Pretty CG, Desaive T, Shaw GM, Chase JG. Accurate end systole detection in dicrotic notch-less arterial pressure waveforms. J Clin Monit Comput 2020; 35:79-88. [PMID: 32048103 DOI: 10.1007/s10877-020-00473-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/24/2020] [Indexed: 11/26/2022]
Abstract
Identification of end systole is often necessary when studying events specific to systole or diastole, for example, models that estimate cardiac function and systolic time intervals like left ventricular ejection duration. In proximal arterial pressure waveforms, such as from the aorta, the dicrotic notch marks this transition from systole to diastole. However, distal arterial pressure measures are more common in a clinical setting, typically containing no dicrotic notch. This study defines a new end systole detection algorithm, for dicrotic notch-less arterial waveforms. The new algorithm utilises the beta distribution probability density function as a weighting function, which is adaptive based on previous heartbeats end systole locations. Its accuracy is compared with an existing end systole estimation method, on dicrotic notch-less distal pressure waveforms. Because there are no dicrotic notches defining end systole, validating which method performed better is more difficult. Thus, a validation method is developed using dicrotic notch locations from simultaneously measured aortic pressure, forward projected by pulse transit time (PTT) to the more distal pressure signal. Systolic durations, estimated by each of the end systole estimates, are then compared to the validation systolic duration provided by the PTT based end systole point. Data comes from ten pigs, across two protocols testing the algorithms under different hemodynamic states. The resulting mean difference ± limits of agreement between measured and estimated systolic duration, of [Formula: see text] versus [Formula: see text], for the new and existing algorithms respectively, indicate the new algorithms superiority.
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Affiliation(s)
- Joel Balmer
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand.
| | - Rachel Smith
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Christopher G Pretty
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA Cardiovascular Science, University of Liège, Liège, Belgium
| | - Geoff M Shaw
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
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Morelli A, Singer M, Ranieri VM, D'Egidio A, Mascia L, Orecchioni A, Piscioneri F, Guarracino F, Greco E, Peruzzi M, Biondi-Zoccai G, Frati G, Romano SM. Heart rate reduction with esmolol is associated with improved arterial elastance in patients with septic shock: a prospective observational study. Intensive Care Med 2016; 42:1528-1534. [PMID: 27101380 DOI: 10.1007/s00134-016-4351-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 04/05/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE Ventricular-arterial (V-A) decoupling decreases myocardial efficiency and is exacerbated by tachycardia that increases static arterial elastance (Ea). We thus investigated the effects of heart rate (HR) reduction on Ea in septic shock patients using the beta-blocker esmolol. We hypothesized that esmolol improves Ea by positively affecting the tone of arterial vessels and their responsiveness to HR-related changes in stroke volume (SV). METHODS After at least 24 h of hemodynamic optimization, 45 septic shock patients, with an HR ≥95 bpm and requiring norepinephrine to maintain mean arterial pressure (MAP) ≥65 mmHg, received a titrated esmolol infusion to maintain HR between 80 and 94 bpm. Ea was calculated as MAP/SV. All measurements, including data from right heart catheterization, echocardiography, arterial waveform analysis, and norepinephrine requirements, were obtained at baseline and at 4 h after commencing esmolol. RESULTS Esmolol reduced HR in all patients and this was associated with a decrease in Ea (2.19 ± 0.77 vs. 1.72 ± 0.52 mmHg l(-1)), arterial dP/dt max (1.08 ± 0.32 vs. 0.89 ± 0.29 mmHg ms(-1)), and a parallel increase in SV (48 ± 14 vs. 59 ± 18 ml), all p < 0.05. Cardiac output and ejection fraction remained unchanged, whereas norepinephrine requirements were reduced (0.7 ± 0.7 to 0.58 ± 0.5 µg kg(-1) min(-1), p < 0.05). CONCLUSIONS HR reduction with esmolol effectively improved Ea while allowing adequate systemic perfusion in patients with severe septic shock who remained tachycardic despite standard volume resuscitation. As Ea is a major determinant of V-A coupling, its reduction may contribute to improving cardiovascular efficiency in septic shock.
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Affiliation(s)
- A Morelli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Viale del Policlinico 155, 00161, Rome, Italy.
| | - M Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, Cruciform Building, London, WC1E 6BT, UK
| | - V M Ranieri
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Viale del Policlinico 155, 00161, Rome, Italy
| | - A D'Egidio
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Viale del Policlinico 155, 00161, Rome, Italy
| | - L Mascia
- Department of Medico-Surgical Sciences and Biotechnologies, University of Rome "La Sapienza", Corso della Repubblica, 79, 04100, Latina, Italy
| | - A Orecchioni
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Viale del Policlinico 155, 00161, Rome, Italy
| | - F Piscioneri
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Viale del Policlinico 155, 00161, Rome, Italy
| | - F Guarracino
- Department of Anesthesia and Intensive Care, Cardiothoracic Anesthesia and Intensive Care Medicine, University Hospital of Pisa, via Roma 55, 56126, Pisa, Italy
| | - E Greco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Viale del Policlinico 155, 00161, Rome, Italy
| | - M Peruzzi
- Department of Medico-Surgical Sciences and Biotechnologies, University of Rome "La Sapienza", Corso della Repubblica, 79, 04100, Latina, Italy
| | - G Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, University of Rome "La Sapienza", Corso della Repubblica, 79, 04100, Latina, Italy
- Department of AngioCardioNeurology, IRCCS Neuromed, Via Atinense 18, 86077, Pozzilli, Italy
| | - G Frati
- Department of Medico-Surgical Sciences and Biotechnologies, University of Rome "La Sapienza", Corso della Repubblica, 79, 04100, Latina, Italy
- Department of AngioCardioNeurology, IRCCS Neuromed, Via Atinense 18, 86077, Pozzilli, Italy
| | - S M Romano
- Unit of Internal Medicine and Cardiology, Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy
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Politi MT, Ghigo A, Fernández JM, Khelifa I, Gaudric J, Fullana JM, Lagrée PY. The dicrotic notch analyzed by a numerical model. Comput Biol Med 2016; 72:54-64. [PMID: 27016670 DOI: 10.1016/j.compbiomed.2016.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/16/2016] [Accepted: 03/13/2016] [Indexed: 10/22/2022]
Abstract
Divergent concepts on the origin of the dicrotic notch are widespread in medical literature and education. Since most medical textbooks explain the origin of the dicrotic notch as caused by the aortic valve closure itself, this is commonly transmitted in medical physiology courses. We present clinical data and numerical simulations to demonstrate that reflected pressure waves could participate as one of the causes of the dicrotic notch. Our experimental data from continuous arterial pressure measurements from adult patients undergoing vascular surgery suggest that isolated changes in peripheral vascular resistance using an intravenous bolus of phenylephrine (a selective alpha 1-receptor agonist and thus a potent vasoconstrictor) modify the dicrotic notch. We then explore the mechanisms behind this phenomenon by using a numerical model based on integrated axisymmetric Navier-Stokes equations to compute the hemodynamic flow. Our model illustrates clearly how modifications in peripheral artery resistance may result in changes in the amplitude of the dicrotic notch by modifying reflected pressure waves. We believe that this could be a useful tool in teaching medical physiology courses.
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Zundel MT, Pattyn M, Chelimsky TC, Riess ML. Arterial flow waveforms, vascular tone, and chronic fatigue: a case report. Auton Neurosci 2015; 190:58-60. [PMID: 25817901 DOI: 10.1016/j.autneu.2015.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 02/09/2015] [Accepted: 03/17/2015] [Indexed: 11/19/2022]
Abstract
We present the case of a patient with chronic fatigue secondary to Postural Orthostatic Tachycardia Syndrome (POTS) who had distinctive abnormalities in his arterial waveform morphology as assessed by pulse oximetry. Moreover, the patient's arterial waveform changed markedly from being supine to upright, suggesting that arterial flow patterns may be abnormal in our patient. Analysis of the waveform suggested a positional hypovolemia as the cause of his orthostatic intolerance. We review general aspects of arterial flow waveform analysis pertinent to health care providers and discuss the pathophysiology of POTS.
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Affiliation(s)
- M Tracy Zundel
- Anesthesia Service, Clement J. Zablocki VA Medical Center, 5000 West National Avenue, Milwaukee, WI 53295, USA; Department of Anesthesiology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Matthew Pattyn
- Department of Anesthesiology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Thomas C Chelimsky
- Department of Neurology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA
| | - Matthias L Riess
- Tennessee Valley Healthcare System VA Medical Center, 1310 24(th) Avenue South, Nashville, TN 37212, USA; Department of Anesthesiology, Vanderbilt University, 1161 21(st) Avenue South, Nashville, TN 37232, USA.
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