Publications by authors named "Natasha Gupta"

49 Publications

Evidence-Based Recommendations for Opioid Prescribing after Endourological and Minimally Invasive Urological Surgery.

J Endourol 2021 Jun 9. Epub 2021 Jun 9.

Johns Hopkins University School of Medicine, Baltimore, Maryland, United States;

Introduction: Procedure-specific guidelines for postsurgical opioid use can decrease overprescribing and facilitate opioid stewardship. Initial recommendations were based on feasibility data from limited pilot studies. This study aims to refine opioid prescribing recommendations for endourological and minimally invasive urological procedures by integrating emerging clinical evidence with a panel consensus.

Methods: A multistakeholder panel was convened with broad subspecialty expertise. Primary literature on opioid prescribing after 16 urological procedures was systematically assessed. Using a modified Delphi technique, the panel reviewed and revised procedure-specific recommendations and opioid stewardship strategies based on additional evidence. All recommendations were developed for opioid-naïve adult patients after uncomplicated procedures.

Results: Seven relevant studies on postsurgical opioid prescribing were identified: four studies on ureteroscopy, two studies on robotic prostatectomy including a combined study on robotic nephrectomy, and one study on transurethral prostate surgery. The panel affirmed prescribing ranges to allow tailoring quantities to anticipated need. The panel noted that zero opioid tablets would be potentially appropriate for all procedures. Following evidence review, the panel reduced the maximum recommended quantities for 11 of the 16 procedures; the other 5 procedures were unchanged. Opioids were no longer recommended following diagnostic endoscopy and transurethral resection procedures. Finally, data on prescribing decisions supported expanded stewardship strategies for first-time prescribing and ongoing quality improvement.

Conclusion: Reductions in initial opioid prescribing recommendations are supported by evidence for most endourological and minimally invasive urological procedures. Shared decision-making prior to prescribing and periodic reevaluation of individual prescribing patterns are strongly recommended to strengthen opioid stewardship.
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http://dx.doi.org/10.1089/end.2021.0250DOI Listing
June 2021

Impact of COVID Lockdown on the Presentation of Nasal Foreign Bodies to a Tertiary Care Center.

Ear Nose Throat J 2020 Dec 14:145561320981438. Epub 2020 Dec 14.

Department of Radiology, 75299Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India.

Background: India announced nationwide lockdown on March 24, 2020, to control the COVID crisis. Due to lockdown, the health care system, that is, delivery and utilization of the health facilities were adversely affected.

Clinical Setting: Presentation and management of nasal foreign body cases over 3 months post COVID lockdown has been discussed. Factors for delayed diagnosis and management are assessed and compared with pre-COVID era.

Result/outcome: Due to lockdown and COVID phobia, more complicated cases of nasal foreign body are presented in post lockdown period.

Conclusion: We need to formulate and standardize the management strategies to avoid such unfortunate circumstances so that even non-COVID cases are managed more appropriately and in a timely manner.
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http://dx.doi.org/10.1177/0145561320981438DOI Listing
December 2020

Massive Ovarian Edema: An Extremely Rare Cause of Ovarian Mass in a 7-Year-Old Girl.

J Indian Assoc Pediatr Surg 2020 Jul-Aug;25(4):256-257. Epub 2020 Jun 24.

Department of Radiology, Chacha Nehru Bal Chikitsalaya, Delhi, India.

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http://dx.doi.org/10.4103/jiaps.JIAPS_111_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478289PMC
June 2020

Understanding Psychosocial and Sexual Health Concerns Among Women With Bladder Cancer Undergoing Radical Cystectomy.

Urology 2021 May 25;151:145-153. Epub 2020 Aug 25.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD.

Objective: To better understand the physical and psychosocial components of female sexual dysfunction (FSD) among women undergoing radical cystectomy (RC) for bladder cancer (BCa).

Methods: We conducted semistructured individual interviews and a focus group with pre- and post-RC female patients and their partners regarding the impact of RC on sexual health and psychosocial wellbeing. Themes were inductively identified by 2 independent coders and subsequently organized into themes and subthemes using qualitative description and constant comparison.

Results: In the preoperative cohort, 6 women and 1 partner participated (50% contact rate, 75% participation rate). In the postoperative cohort, 16 women and 2 partners participated (61% contact rate, 64% participation rate). Major themes that emerged in interviews with both cohorts included concerns about changes to body image, the psychological impact of BCa diagnosis and treatment, concerns about the impact of RC on sexual function, and inadequacies in provider-led sexual health counseling. Participants varied in the importance they placed on sexual function, with factors such as age, relationship status, and oncologic concerns impacting prioritization, although both younger and older patients expressed a desire to retain the option of sexual function.

Conclusion: Female patients with BCa undergoing RC experience changes in body image, psychological distress, physical disruptions in sexual function, and inadequacies in sexual health counseling and education. Future efforts should be directed towards improving sexual health counseling and psychosocial support resources for women with BCa.
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http://dx.doi.org/10.1016/j.urology.2020.08.018DOI Listing
May 2021

A Comparison of Surgical Outcomes between Single-Site Robotic, Multiport Robotic and Conventional Laparoscopic Techniques in Performing Hysterectomy for Benign Indications.

Gynecol Minim Invasive Ther 2020 Apr-Jun;9(2):59-63. Epub 2020 Apr 28.

Department of Minimally Invasive Gynecologic Surgery, University of Tennessee College of Medicine, Chattanooga, Tennessee, USA.

Objectives: Minimally invasive gynecologic surgery (MIGS) is the standard of care in performing hysterectomy for benign conditions. However, the choice of laparoscopic modality is largely dependent on surgeon's discretion, experience, and equipment availability. The objective of this study is: To compare outcomes between different minimally invasive approaches available for benign hysterectomies and to evaluate patient factors that influence the use of one approach over another. With this study, we sought to provide some objective criteria while deciding the appropriate MIGS technique.

Materials And Methods: This is a retrospective study comparing perioperative outcomes between three techniques of minimally invasive hysterectomy: laparoscopy (LSC), multiport daVinci (MP-Rob) and single-site daVinci (SS-Rob). Patients undergoing benign hysterectomy (daVinci or conventional LSC) from January 2015 to July 2016 were included. 129 patients were identified and divided into: LSC ( = 44), MP-Rob ( = 36) and SS-Rob ( = 49).

Results: There were statistically significant differences in age (MP-Rob46 ≠ LSC39), body mass index (BMI) (MP-Rob33 ≠ LSC27 or SS-Rob26.8), uterus weight (MP-Rob144 ≠ LSC102 or SS-Rob105) and operative time (LSC192 ≠ SS-Rob162.3 or MP-Rob163). Chi-square analyses revealed history of endometriosis and clinical endometriosis was statistically less common while leiomyomas were more common indications of MP-Rob. There was no statistically significant difference noted between length of stay, estimated blood loss, intraoperative, and post-operative complications between different surgical types.

Conclusion: Patients with higher age, BMI, uterus weight and abnormal uterine bleeding were noted to undergo MP-Rob surgery. Patients with history of endometriosis were more likely to undergo LSC or SS-Rob surgery. Operative time was significantly less for daVinci hysterectomies (SS-Rob and MP-Rob) as compared to conventional LSC.
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http://dx.doi.org/10.4103/GMIT.GMIT_68_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354752PMC
April 2020

Benign vascular anomalies: A transition from morphological to etiological classification.

Ann Diagn Pathol 2020 Jun 13;46:151506. Epub 2020 Mar 13.

Department of Radiodiagnosis, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi 110031, India.

The International Society for the Study of Vascular Anomalies (ISSVA) devised a multidisciplinary etiopathogenesis based approach to classify benign vascular anomalies into tumors and malformations. This classification scheme has major therapeutic and prognostic implications as treatment modalities differ for both the categories. Inappropriate usage of the term "hemangioma" for etiopathogenetically distinct entities is commonly seen in clinical practice leading to delivery of incorrect treatment to the patients. We aimed to study the histomorphological and immunohistochemical features of benign vascular anomalies for their precise histopathological classification. A total of 48 cases diagnosed over a period of 3.5 years were reviewed and reclassified into vascular tumors and malformations based on ISSVA classification and prototypical histopathological features. Biopsies were reviewed based on 5 histopathological criteria viz. endothelial morphology, mitotic activity, intralesional nerve bundles, intralesional inflammation, and prominent vessel type. A panel of GLUT-1, WT-1, and Ki-67 was performed in each case. Seven cases of infantile hemangioma, 4 cases each of non-involuting congenital hemangioma and pyogenic granuloma, and 33 cases of vascular malformations were diagnosed. Endothelial cell morphology (p < 0.001), mitotic activity (p < 0.001), and intralesional nerve bundles (p < 0.001) were found to be statistically significant in differentiating hemangioma from malformations. GLUT-1 (p < 0.001) and Ki-67 labeling index (p < 0.001) were useful to distinguish infantile hemangioma from vascular malformations. To conclude, the ISSVA classification of benign vascular anomalies can be reliably done on histopathology. However, every case must be interpreted in the light of clinical and radiological features.
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http://dx.doi.org/10.1016/j.anndiagpath.2020.151506DOI Listing
June 2020

Comparing Provider-Led Sexual Health Counseling of Male and Female Patients Undergoing Radical Cystectomy.

J Sex Med 2020 05 12;17(5):949-956. Epub 2020 Mar 12.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Sexual dysfunction is a common quality-of-life issue among patients undergoing radical cystectomy (RC) for bladder cancer, but patients report deficiencies in sexual health counseling.

Aim: We sought to characterize provider-led sexual health counseling of patients undergoing RC and whether provider practice differs by patient gender.

Methods: We conducted a cross-sectional survey of members of the Society of Urologic Oncology to assess topics included in provider-led sexual health counseling and barriers to counseling.

Outcomes: Nonroutine counseling regarding each sexual health topic was compared for female vs male patients using chi-squared tests. Modified Poisson regression was used to examine associations between provider characteristics and nonroutine counseling of female patients.

Results: Among 140 urologists, the majority did not routinely counsel patients about sexual orientation, partner sexual dysfunction, or referral options to sexual health services. Providers were significantly more likely to not provide routine counseling to female patients compared to male patients about the following topics: baseline sexual activity (20.6% vs 9.7%, respectively, P = 0.04), baseline sexual dysfunction (60.8% vs 20.2%, respectively, P < 0.05), the risk of sexual dysfunction after RC (20.0% vs 6.5%, respectively, P = 0.006), the potential for nerve-sparing RC (70.8% vs 35.5%, respectively, P = 0.002), and postoperative sexual health and dysfunction (42.6% vs 21.1%, respectively, P = 0.01). Overall, 41.2% of providers did not routinely discuss the potential for pelvic organ-preserving RC with sexually active female patients. Provider sex, age, practice type, urologic oncology fellowship training, years in practice, or female RC volume were not predictive of nonroutine or disparate counseling of female patients. The most common barriers to counseling female patients were older patient age (50.7%), inadequate time (47.1%), and uncertainty about baseline sexual function (37.1%).

Clinical Implications: Urologists acknowledge key deficiencies and gender disparities in sexual health counseling of patients undergoing RC.

Strengths And Limitations: Although cross-sectional, to our knowledge, this is the first study to examine provider practice patterns regarding sexual health counseling of patients undergoing RC.

Conclusion: Future efforts should be directed towards reducing barriers to sexual health counseling of patients undergoing RC to improve deficiencies and gender disparities. Gupta N, Kucirka LM, Semerjian A, et al. Comparing Provider-Led Sexual Health Counseling of Male and Female Patients Undergoing Radical Cystectomy. J Sex Med 2020;17:949-956.
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http://dx.doi.org/10.1016/j.jsxm.2020.01.025DOI Listing
May 2020

Reducing preoperative blood orders and costs for radical prostatectomy.

J Comp Eff Res 2020 02 11;9(3):219-226. Epub 2020 Feb 11.

The James Buchanan Brady Urological Institute & Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.

A maximum surgical blood order schedule (MSBOS) was implemented at our institution to optimize preoperative blood ordering and reduce unnecessary blood preparation for patients undergoing radical prostatectomy (RP), a common urologic procedure. We conducted a retrospective review of patients who underwent RP from 2010 to 2016 and categorized patients by date of RP (pre- or post-MSBOS) and compared preoperative blood-ordering practices. After MSBOS implementation, preoperative blood orders changed from predominantly type and cross-match 2 units (53%) to no sample (56%) for robot-assisted laparoscopic RP, and from mostly type and cross-match 2 units (62%) to type and screen (75%) for open RP with resultant cost savings. MSBOS implementation and compliance decreases unnecessary preoperative blood orders.
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http://dx.doi.org/10.2217/cer-2019-0126DOI Listing
February 2020

Non-malignant fibroblastic/myofibroblastic tumors in pediatric age group: Clues and pitfalls to the cytological diagnosis.

Cytopathology 2020 03 7;31(2):115-121. Epub 2020 Feb 7.

Department of Paediatric Surgery, Chacha Nehru Bal Chikitsalaya, New Delhi, India.

Introduction: Fibroblastic/myofibroblastic tumors constitute 12% of all pediatric soft tissue tumors with the majority of them belonging to the benign and intermediate prognostic categories. They are often misdiagnosed owing to their variable clinical presentation and unusual microscopic features. The diagnosis, specially cytological diagnosis of benign and intermediate categories is difficult due to paucity of cellular component and increased amount of extracellular matrix as compared to malignant ones. We hereby discuss the Fine needle aspiration cytology (FNAC) findings of non-malignant fibroblastic/myofibroblastic lesion in the pediatric age group encountered at our institute.

Methods: All the benign and intermediate fibroblastic/myofibroblastic/fibroadipocytic lesions (age 0-12 years) diagnosed on FNAC over a period of 3½ years (Jan 2016- July 2019), with availability of corresponding histopathology were included in the study.

Results: A total of seven pediatric benign and intermediate fibroblastic/myofibroblastic lesions with histopathological confirmation were identified which included Infantile digital fibromatosis (IDF) (n = 2), Lipofibromatosis (n = 1), Fibrous hamartoma of infancy (FHI) (n = 1), Fibromatosis colli (FC) (n = 2) and myofibroma/myofibromatosis (n = 1). FNAC smears were mainly paucicellular with presence of benign spindle shaped cells in a collagenous stroma common to almost all the cases. A few additional findings such as degenerated skeletal muscle fibres, muscle giant cells and mature adipose tissue were also present in some cases.

Conclusion: Fibroblastic/myofibroblastic tumors although uncommon, form an important category that must be considered in the differential diagnosis of pediatric soft tissue tumors. FNAC cytology features when assessed in a proper clinical setting (specially the age and site of presentation) are helpful in suggesting probable preoperative diagnosis in these lesions.
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http://dx.doi.org/10.1111/cyt.12786DOI Listing
March 2020

Scimitar Syndrome: An Incidental Finding.

Indian J Pediatr 2020 02 9;87(2):165-166. Epub 2019 Nov 9.

Department of Pediatrics, Chacha Nehru Bal Chikitsalya, New Delhi, India.

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http://dx.doi.org/10.1007/s12098-019-03083-3DOI Listing
February 2020

Reply by Authors.

J Urol 2020 01 3;203(1):157-158. Epub 2019 Oct 3.

Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

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http://dx.doi.org/10.1097/01.JU.0000602700.36916.06DOI Listing
January 2020

Recommendations for Opioid Prescribing after Endourological and Minimally Invasive Urological Surgery: An Expert Panel Consensus.

J Urol 2020 01 29;203(1):151-158. Epub 2019 Aug 29.

Department of Urology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Purpose: Opioids are frequently overprescribed after surgery. The 2018 AUA position statement on opioid use suggests using the lowest dose and potency to achieve pain control but the lack of procedure specific prescribing guidelines contributes to wide variation in prescribing patterns. To address this gap we aimed to develop opioid prescribing recommendations through an expert panel consensus.

Materials And Methods: The 15-member multidisciplinary expert panel included representatives from 5 stakeholder groups. A 3-step modified Delphi method was used to develop recommendations for postoperative opioid prescribing. Recommendations were made for opioid naïve patients without chronic pain conditions. The panel used oxycodone 5 mg equivalents to define the number of prescribed tablets.

Results: Procedure specific recommendations were developed for 16 endourological and minimally invasive urological procedures. The panel agreed that not all patients desire or require opioids and, thus, the minimum recommended number of opioid tablets for all procedures was 0. Consensus ranges were identified to allow prescribed quantities to be aligned with expected needs. The maximum recommended quantity varied by procedure from 0 tablets (3 procedures) to 15 tablets (6 procedures) with a median of 10 tablets. Attending urologists typically voted for higher opioid quantities than nonattending panel members. The panel identified 8 overarching strategies for opioid stewardship, including contextualizing postoperative pain management with patient goals and preferences, and maximizing nonopioid therapies.

Conclusions: Procedure specific guidelines for postoperative opioid prescribing may help align individual urologist prescribing habits with consensus recommendations. These guidelines can aid quality improvement efforts to reduce overprescribing in urology.
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http://dx.doi.org/10.1097/JU.0000000000000514DOI Listing
January 2020

Evaluating the impact of length of time from diagnosis to surgery in patients with unfavourable intermediate-risk to very-high-risk clinically localised prostate cancer.

BJU Int 2019 08 27;124(2):268-274. Epub 2019 Jan 27.

The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objective: To evaluate the impact of length of time from diagnostic biopsy to radical prostatectomy (RP) on oncological outcomes amongst men diagnosed with unfavourable intermediate- to very-high-risk clinically localised prostate cancer.

Patients And Methods: We performed a retrospective review of men with a diagnosis of grade group (GG) ≥3 prostate cancer on biopsy, who underwent RP within 6 months of diagnosis, at our institution between 2005 and 2018. We assessed patient demographics, pre-biopsy disease characteristics, and receipt of neoadjuvant therapy. We categorised time between biopsy and RP into two intervals: <3 and 3-6 months. For each GG, we compared receipt of adjuvant therapy, pathological outcomes at RP (positive surgical margin [PSM], extraprostatic extension [EPE], seminal vesicle invasion [SVI], and lymph node involvement [LNI]), risk of 2- and 5-year biochemical recurrence-free survival (BCRFS), and 2-, 5-, and 10-year metastasis-free survival (MFS) between patients who underwent RP at <3 vs 3-6 months after diagnosis.

Results: Amongst 2303 men who met the study inclusion criteria, 1244 (54%) had GG 3, 608 (26%) had GG 4, and 451 (20%) had GG 5 disease. In all, 72% underwent RP at <3 months after diagnosis. For each diagnostic GG, there was no significant difference in rates of adjuvant therapy, PSM, EPE, SVI, or LNI in men who had RP at <3 vs 3-6 months after diagnosis. In all, 1568 men had follow-up after RP of >1 year. For each diagnostic GG, there was no significant difference in 2- and 5-year BCRFS between patients who had RP at <3 vs 3-6 months after diagnosis (GG 3: 78% vs 83% and 69% vs 66%, respectively, P = 0.6; GG 4: 68% vs 74% and 51% vs 57%, respectively, P = 0.4; GG 5: 58% vs 74% and 48% vs 54%, respectively, P = 0.2). Similarly, for each diagnostic GG, there was no significant difference in 2-, 5-, and 10-year MFS between patients who had RP at <3 vs 3-6 months after diagnosis, although we were not able to calculate 10-year MFS for patients with GG 5 disease due to limited follow-up in that group (GG 3: 98%, 92%, and 84% vs 97%, 95%, and 91%, respectively, P = 0.4; GG 4: 97%, 90%, and 72% vs 94%, 91%, and 81%, respectively, P = 0.8; GG 5: 89% and 81% vs 91% and 71%, respectively, P = 0.9).

Conclusions: Waiting for RP up to 6 months after diagnosis is not associated with adverse outcomes amongst patients with unfavourable intermediate- to very-high-risk prostate cancer.
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http://dx.doi.org/10.1111/bju.14659DOI Listing
August 2019

Scheuermann's Disease with Extensive Involvement of Dorsolumbar Spine.

Indian J Pediatr 2018 09 3;85(9):818-819. Epub 2018 May 3.

Department of Pediatrics, University College of Medical Sciences and GTB Hospital, Dilshad Garden, Delhi, 110 095, India.

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http://dx.doi.org/10.1007/s12098-018-2675-3DOI Listing
September 2018

Perioperative outcomes of robotic hysterectomy with mini-laparotomy versus open hysterectomy for uterus weighing more than 250 g.

J Robot Surg 2018 Dec 16;12(4):641-645. Epub 2018 Feb 16.

Department of Gynecologic Oncology, University of Tennessee College of Medicine, Chattanooga, TN, 37403, USA.

To compare perioperative outcomes in patients undergoing robotic hysterectomy and extraction of specimen via mini-laparotomy (RHML) versus open hysterectomy (OH) when uterus weighs more than 250 g. To study the factors determining the length of hospital stay in 2 groups. A retrospective analysis of all hysterectomies performed for uterus weighing more than 250 g from the year 2012 to 2015 was conducted. A total of 140 patients were divided into 2 groups based on the type of surgery; RHML (n = 82) and OH (n = 58). Mini-laparotomy consisted of a customised incision connecting 2 left lateral port sites for specimen extraction after completing the hysterectomy robotically. Patient factors and perioperative outcomes were compared using Student's t tests and Chi-square analysis. Mean length of stay (RHML = 1.4 days; OH = 3.4 days), estimated blood loss (EBL) (RHML = 119.9 ml; OH = 547.5 ml) and operative time (RHML = 191.5 min; OH = 162.8 min) were significantly different. No significant differences were noted for patient BMI, age, comorbidities, intraoperative complications, pathology of uterus and uterus weight. Postoperative complications were significantly different between two groups (RHML = 6.0%; OH = 15.5%; p = .021). None of the patients stayed less than 24 h in OH group compared to 59.8% patients in RHML group. Type of procedure (p = .004) and EBL (p = .002) significantly predicted the length of stay. Patients undergoing RHML have significantly shorter length of stay, EBL and postoperative complications than OH. The operative time for RHML was longer than OH, but the overall decreased length of stay overcomes this disadvantage. RHML approach retains the benefits of da Vinci, while simultaneously preserving the specimen.
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http://dx.doi.org/10.1007/s11701-018-0792-7DOI Listing
December 2018

Paint in the Pipe: An Unusual Foreign Body.

Indian Pediatr 2017 Nov;54(11):963-965

Departments of Pediatrics and *Radiology, University College of Medical Sciences (University of Delhi) and GTB Hospital, Dilshad Garden, Delhi, India. Correspondence to: Dr Dheeraj Shah, Professor, Department of Pediatrics, University College of Medical Sciences and GTB Hospital, Dilshad Garden, Delhi 110 095, India.

Background: Foreign bodies in the airway can be a diagnostic and therapeutic challenge.

Case Characteristics: 30-month-old girl with complaints of noisy and fast breathing following fall over a pile of sand. Sand was suctioned out by direct bronchoscopy. The child improved initially but condition worsened in next four days with marked stridor and wheeze.

Observation: Imaging revealed elongated sharp radiodense opacity in the cervical region, suggestive of foreign body. At repeat bronchoscopy, paint material was removed from the airway, leading to recovery.

Message: Paint material mixed in the sand can adhere to the walls of the airway, and cause persistent symptoms of obstruction.
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http://dx.doi.org/10.1007/s13312-017-1192-1DOI Listing
November 2017

Etiology and Risk Factors Determining Poor Outcome of Severe Pneumonia in Under-Five Children.

Indian J Pediatr 2018 Jan 13;85(1):20-24. Epub 2017 Oct 13.

Department of Pediatrics, University College of Medical Sciences & GTB Hospital, Dilshad Garden, Delhi, 110095, India.

Objectives: To determine the etiology of severe pneumonia (pneumonia with chest indrawing) in under-five children, and to study the risk factors for poor outcomes viz., 'treatment failure', 'need for change in antibiotics', 'prolonged hospital stay', 'need for mechanical ventilation' and 'mortality.'

Methods: Children (age 2 mo to 5 y) with pneumonia and chest drawing were enrolled prospectively from October 2012 through September 2013. Clinical history was recorded, and examination, anthropometry and investigations (including chest X-ray, blood culture and nasopharyngeal swab culture) were performed. Children were managed as per standard guidelines, and recovery outcomes were recorded in form of 'treatment failure' (defined as persistence of features of severe pneumonia after 72 h or worsening of clinical condition before 72 h), need for change of antibiotics and prolonged (>5 d) hospital stay. The associations between the clinical, anthropometric and diagnostic risk factors and the recovery outcomes were evaluated by univariate and multivariate logistic regression analysis.

Results: Out of 120 children enrolled in the study, 36 (42%) were culture positive (nasopharyngeal/blood); most common bacteria isolated were Streptococcal pneumoniae and Staphylococcal aureus, respectively. Treatment failure was seen in 15 (12.5%), 34 (28.3%) needed change of antibiotics, and 50 (41.6%) children required prolonged hospitalization. Low birth weight, overcrowding, general danger signs (lethargy/unable to drink), clinical rickets, crepitation, leukocytosis and positive blood culture were significant risk factors for treatment failure, prolonged hospital stay and antibiotics change. On multivariate logistic regression analysis, respiratory rate of >70/min (OR 19.94, 95%CI 1.42-280.29), lethargy/unconsciousness (OR 114.2, 95%CI 3.14-4147.92), and positive blood culture (OR 15.24, 95%CI 2.53-91.67) had more chances of treatment failure. Duration of hospital stay was prolonged in those who had inability to drink (OR 3.89, CI 1.37-10.99) or abnormal chest X-ray (OR 8.45, CI 3.56-20.04). Children with rickets (OR 3.69, CI 1.14-11.96), and those with abnormal chest X-ray (OR 9.66, CI 2.62-35.53) had a higher odds of change in antibiotics. Presence of wheeze was a protective factor for treatment failure (OR 0.03, CI 0.00-0.37) and change of antibiotics (OR 0.24, CI 0.07-0.74).

Conclusions: Staphylococcus aureus and Streptococcus pneumoniae are the predominant organisms causing severe pneumonia in our setting. Children with risk factors such as respiratory rate >70/min, rickets, lethargy/unconsciousness, not able to drink, abnormal chest X-ray or positive blood culture are likely to have a delayed recovery or need of change of antibiotics, whereas those with wheeze are likely to recover faster with less chances of treatment failure.
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http://dx.doi.org/10.1007/s12098-017-2514-yDOI Listing
January 2018

Management and Excision of a 15 cm Paratesticular Angiolipoma.

Urol Case Rep 2017 Nov 18;15:8-10. Epub 2017 Aug 18.

James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA.

Paratesticular tumors are rare and often benign causes of scrotal masses. Intrascrotal angiolipomas are an uncommon paratesticular tumor that has seldom been reported in the literature. This report describes a 77 year old man who presented with a 15 cm extratesticular mass. The mass was removed due to increasing discomfort and specimen pathology confirmed it as an angiolipoma. This case highlights the feasibility of conservative management for slow growing masses, such as angiolipomas.
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http://dx.doi.org/10.1016/j.eucr.2017.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5565739PMC
November 2017

Optimal Utilization of Pediatric Computed Tomography to Minimize Radiation Exposure: What the Clinician Must Know s.

Indian Pediatr 2017 Jul;54(7):581-585

Department of Radiology and Imaging, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi, India. Correspondence to: Dr Natasha Gupta, Specialist, Department of Radiology and Imaging, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi, India.

The number of computed tomography (CT) scans being done for children all over the world is on the rise ever since the advent of Multi-Detector CT (MDCT). However, CT is a potential source of harmful ionizing radiation, and children are more susceptible to its adverse effects. It is essential for the pediatrician as well as the radiologist to be aware of some important principles and guidelines, by following which, radiation exposure to the child can be minimized to the bare essential. It is important to have knowledge of the valid and justifiable indications of CT for the child, the correct technique of performing the scan, and the new technological innovations now available on modern scanners that help to minimize radiation dose.
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http://dx.doi.org/10.1007/s13312-017-1072-8DOI Listing
July 2017

Long Bone Fractures Associated with Abdominal Breech Deliveries: A Report of Two Cases.

J Reprod Med 2017 May-Jun;62(5-6):333-6

BACKGROUND: Birth-related injuries are a well-known complication of vaginal breech deliveries but are not anticipated during cesarean breech deliveries. However, long bone fractures in the neonate can result from delivery of the breech presentation by cesarean section. CASES: We report 2 cases of long bone fractures that occurred during cesarean section for breech presentation. No underlying bone pathology or systemic illness could be identified in either case. There were no other predisposing risk factors for fractures except breech presentation. Both infants were managed with cast application and outpatient physical therapy and recovered without any residual deformity. CONCLUSION: Obstetricians should be aware of the possibility of long bone fractures with abdominal breech deliveries. Their prompt recognition and conservative management, including physical therapy, can prevent bone deformities.
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January 2019

Mortality trends and the impact of lymphadenectomy on survival for renal cell carcinoma patients with distant metastasis.

Can Urol Assoc J 2016 Nov-Dec;10(11-12):389-395

James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, United States.

Introduction: Current treatment paradigms for metastatic renal cell carcinoma (mRCC) invoke a combination of surgical and systemic therapies. We sought to quantify trends in mortality and performance of lymphadenectomy, as well as impact on survival for patients with mRCC.

Methods: The Surveillance, Epidemiology, and End Results registry (SEER) (1988-2011) identified patients with mRCC. Kaplan-Meier curves and Cox proportional hazards models with competing risks regression were employed to assess survival.

Results: 15 060 patients with mRCC were identified, with 6316 (41.9%) undergoing cytoreductive nephrectomy. Mean number of lymph nodes removed was 6.2, with mean 3.3 positive nodes among 1018 (43.9%) patients with positive nodes. Median overall survival (OS) increased from seven to 11 months (1999-2010), and finding a positive node decreased median cancer survival from 22 to nine months. Cancer-specific survival (CSS) showed significant decreases in mortality after 2005 (hazard ratio [HR] 0.71 [0.60-0.83] comparing 2010 to 1990). Lymphadenectomy was associated with decreased OS (HR 1.10 [1.03-1.16]; p=0.002) due to decreased CSS (HR 1.10 [1.04-1.17]; p<0.001) without increase in other-cause mortality (HR 0.94 [0.79-1.11]; p=0.455). However, more extensive lymphadenectomy ≥3 lymph nodes removed did not significantly impact OS or CSS. Number of positive lymph nodes was associated with decreased CSS.

Conclusions: mRCC continues to carry a poor prognosis, but current treatment paradigms have led to modest improvements in OS and CSS in recent years. Lymphadenectomy was found to play a prognostic rather than therapeutic role in the management of mRCC. The performance of lymphadenectomy should be limited based on clinical judgment and better incorporated into randomized trials of new systemic therapies to identify scenarios where implementation may improve survival.
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http://dx.doi.org/10.5489/cuaj.1999DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5167593PMC
January 2017

Large Cell Calcifying Sertoli Cell Tumour of Testis-A Rare Case Report.

J Clin Diagn Res 2016 Nov 1;10(11):ED03-ED05. Epub 2016 Nov 1.

Director and Professor, Department of Pathology, University College of Medical Sciences , Dilshad Garden, Delhi, India .

Sertoli cell tumours of testes are classified into sertoli cell tumour NOS (not otherwise specified), sclerosing variant and large cell calcifying variant. So far, 90 cases of the large cell calcifying variant have been reported in literature. We describe a rare case of inhibin negative locally invasive large cell calcifying sertoli cell tumour of testis. A 62-year-old man presented with complaints of pain and swelling in right scrotum for 8 months. Ultrasound revealed a right testicular mass with internal vascularity and calcification. Gross examination of right inguinal orchiectomy specimen showed firm to hard mass with yellow areas and calcification seen on cut section. Microscopy revealed a tumour in the testis infiltrating the epididymis and rete testis and reaching up to the skin. Tumour cells were arranged in the form of solid nests, tubules and cords with neutrophilic stromal infiltrate and calcification. Tumour cells had abundant clear to eosinophilic cytoplasm, round nucleus with vesicular chromatin and conspicuous nucleoli. On immunohistochemistry, tumour cells were positive for pan cytokeratin, Epithelial Membrane Antigen (EMA), S-100 protein, desmin, vimentin, neuron specific enolase, and chromogranin. However, it was negative for inhibin alpha, OCT4, CD10, CD99, Melan A. Inhibin negative large cell calcifying sertoli cell tumour is a rare entity.
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http://dx.doi.org/10.7860/JCDR/2016/22075.8842DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198331PMC
November 2016

Sarin (GB, O-isopropyl methylphosphonofluoridate) neurotoxicity: critical review.

Crit Rev Toxicol 2016 11 5;46(10):845-875. Epub 2016 Oct 5.

a Department of Pharmacology and Cancer Biology , Duke University , Durham , NC , USA.

Sarin (GB, O-isopropyl methylphosphonofluoridate) is a potent organophosphorus (OP) nerve agent that inhibits acetylcholinesterase (AChE) irreversibly. The subsequent build-up of acetylcholine (ACh) in the central nervous system (CNS) provokes seizures and, at sufficient doses, centrally-mediated respiratory arrest. Accumulation of ACh at peripheral autonomic synapses leads to peripheral signs of intoxication and overstimulation of the muscarinic and nicotinic receptors, which is described as "cholinergic crisis" (i.e. diarrhea, sweating, salivation, miosis, bronchoconstriction). Exposure to high doses of sarin can result in tremors, seizures, and hypothermia. More seriously, build-up of ACh at neuromuscular junctions also can cause paralysis and ultimately peripherally-mediated respiratory arrest which can lead to death via respiratory failure. In addition to its primary action on the cholinergic system, sarin possesses other indirect effects. These involve the activation of several neurotransmitters including gamma-amino-butyric acid (GABA) and the alteration of other signaling systems such as ion channels, cell adhesion molecules, and inflammatory regulators. Sarin exposure is associated with symptoms of organophosphate-induced delayed neurotoxicity (OPIDN) and organophosphate-induced chronic neurotoxicity (OPICN). Moreover, sarin has been involved in toxic and immunotoxic effects as well as organophosphate-induced endocrine disruption (OPIED). The standard treatment for sarin-like nerve agent exposure is post-exposure injection of atropine, a muscarinic receptor antagonist, accompanied by an oxime, an AChE reactivator, and diazepam.
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http://dx.doi.org/10.1080/10408444.2016.1220916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5764759PMC
November 2016

Cost and radiation exposure in the workup of febrile pediatric urinary tract infections.

J Surg Res 2016 06 26;203(2):313-8. Epub 2016 Mar 26.

Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address:

Background: Technetium-99m dimercaptosuccinic acid (DMSA) scans are often used in the evaluation of pediatric patients with febrile urinary tract infections (UTIs). Given the prevalence of febrile UTIs, we sought to quantify the cost, radiation exposure, and clinical utility of DMSA scans when compared with dedicated pediatric renal ultrasounds (RUSs).

Materials And Methods: An institutional review board approved retrospective study of children under the age of 18 years evaluated at our institution for febrile UTIs between the years 2004-2013 was conducted. The patients had to meet all of the following inclusion criteria: a diagnosis of vesicoureteral reflux, a fever >38°C, a positive urine culture, and evaluation with a DMSA scan and RUS. A chart review was used to construct a cost analysis of technical and professional fees, radiographic results, and radiation dose equivalents.

Results: Overall, 104 children met the inclusion criteria. A total of 122 RUS and 135 DMSA scans were performed. The technical costs of a DMSA scan incurred a 35% cost premium as compared to an RUS. The average effective radiation dose of a single DMSA scan was 2.84 mSv. New radiographic findings were only identified on 7% of those patients who underwent greater than 1 DMSA scan.

Conclusions: The utility of the unique information acquired from a DMSA scan as compared to a RUS in the evaluation of febrile UTI must be evaluated on an individual case-by-case basis given the increased direct costs and radiation exposure to the patient.
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http://dx.doi.org/10.1016/j.jss.2016.03.042DOI Listing
June 2016

Ovarian Vein Thrombosis as a Complication of Laparoscopic Surgery.

Case Rep Obstet Gynecol 2015 14;2015:682941. Epub 2015 Dec 14.

Department of Obstetrics and Gynecology, Mount Sinai Hospital, 1500 S California Avenue, Chicago, IL 60608, USA.

Ovarian vein thrombosis (OVT) is an extremely rare but life-threatening complication of the postpartum period. It has never been reported as a complication of laparoscopic surgery. We report a case of right ovarian vein thrombosis that occurred in the postoperative period after patient underwent laparoscopic salpingectomy for a right side ectopic pregnancy. She presented with 1-week history of abdominal pain and fever. A complete workup for fever was performed and was found negative. Computed tomography of the abdomen and pelvis revealed right ovarian vein thrombosis. The patient was treated with anticoagulant therapy and responded well.
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http://dx.doi.org/10.1155/2015/682941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691616PMC
January 2016

The Changing Scenario of Obstetrics and Gynecology Residency Training.

J Grad Med Educ 2015 Sep;7(3):401-6

Background: Significant changes have been noted in aspects of obstetrics-gynecology (ob-gyn) training over the last decade, which is reflected in Accreditation Council for Graduate Medical Education (ACGME) operative case logs for graduating ob-gyn residents.

Objective: We sought to understand the changing trends of ob-gyn residents' experience in obstetric procedures over the past 11 years.

Methods: We analyzed national ACGME procedure logs for all obstetric procedures recorded by 12 728 ob-gyn residents who graduated between academic years 2002-2003 and 2012-2013.

Results: The average number of cesarean sections per resident increased from 191.8 in 2002-2003 to 233.4 in 2012-2013 (17%; P < .001; 95% CI -47.769 to -35.431), the number of vaginal deliveries declined from 320.8 to 261 (18.6%; P < .001; 95% CI 38.842-56.35), the number of forceps deliveries declined from 23.8 to 8.4 (64.7%; P < .001; 95% CI 14.061-16.739), and the number of vacuum deliveries declined from 23.8 to 17.6 (26%; P < .001; 95% CI 5.043-7.357). Between 2002-2003 and 2007-2008, amniocentesis decreased from 18.5 to 11 (P < .001, 95% CI 6.298-8.702), and multifetal vaginal deliveries increased from 10.8 to 14 (P < .001, 95% CI -3.895 to -2.505). Both were not included in ACGME reporting after 2008.

Conclusions: Ob-gyn residents' training experience changed substantially over the past decade. ACGME obstetric logs demonstrated decreases in volume of vaginal, forceps, and vacuum deliveries, and increases in cesarean and multifetal deliveries. Change in experience may require use of innovative strategies to help improve residents' basic obstetric skills.
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http://dx.doi.org/10.4300/JGME-D-14-00730.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4597951PMC
September 2015

Changes in Frailty After Kidney Transplantation.

J Am Geriatr Soc 2015 Oct 29;63(10):2152-7. Epub 2015 Sep 29.

Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland.

Objectives: To understand the natural history of frailty after an aggressive surgical intervention, kidney transplantation (KT).

Design: Prospective cohort study (December 2008-March 2014).

Setting: Baltimore, Maryland.

Participants: Kidney transplantation recipients (N = 349).

Measurements: The Fried frailty score was measured at the time of KT and during routine clinical follow-up. Using a Cox proportional hazards model, factors associated with improvements in frailty score after KT were identified. Using a longitudinal analysis, predictors of frailty score changes after KT were identified using a multilevel mixed-effects Poisson model.

Results: At KT, 19.8% of recipients were frail; 1 month after KT, 33.3% were frail; at 2 months, 27.7% were frail; and at 3 months, 17.2% were frail. On average, frailty scores had worsened by 1 month (mean change 0.4, P < .001), returned to baseline by 2 months (mean change 0.2, P = .07), and improved by 3 months (mean change -0.3, P = .04) after KT. The only recipient or transplant factor associated with improvement in frailty score after KT was pre-KT frailty (hazard ratio = 2.55, 95% confidence interval (CI) = 1.71-3.82, P < .001). Pre-KT frailty status (relative risk (RR) = 1.49, 95% CI = 1.29-1.72, P < .001), recipient diabetes mellitus (RR = 1.26, 95% CI = 1.08-1.46, P = .003), and delayed graft function (RR = 1.22, 95% CI = 1.04-1.43, P = .02) were independently associated with long-term changes in frailty score.

Conclusion: After KT, in adult recipients of all ages, frailty initially worsens but then improves by 3 months. Although KT recipients who were frail at KT had higher frailty scores over the long term, they were most likely to show improvements in their physiological reserve after KT, supporting the transplantation in these individuals and suggesting that pretransplant frailty is not an irreversible state of low physiological reserve.
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http://dx.doi.org/10.1111/jgs.13657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618021PMC
October 2015

Imaging for diagnosis of foreign body aspiration in children?

Indian Pediatr 2015 Aug;52(8):659-60

Department of Radiology and Imaging, University College of Medical Sciences and Guru Tegh Bahadur Hospital, Delhi, India.

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August 2015

Autism-Associated Insertion Mutation (InsG) of Shank3 Exon 21 Causes Impaired Synaptic Transmission and Behavioral Deficits.

J Neurosci 2015 Jul;35(26):9648-65

Departments of Neurology and Neurotherapeutics and Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8813

SHANK3 (also known as PROSAP2) is a postsynaptic scaffolding protein at excitatory synapses in which mutations and deletions have been implicated in patients with idiopathic autism, Phelan-McDermid (aka 22q13 microdeletion) syndrome, and other neuropsychiatric disorders. In this study, we have created a novel mouse model of human autism caused by the insertion of a single guanine nucleotide into exon 21 (Shank3(G)). The resulting frameshift causes a premature STOP codon and loss of major higher molecular weight Shank3 isoforms at the synapse. Shank3(G/G) mice exhibit deficits in hippocampus-dependent spatial learning, impaired motor coordination, altered response to novelty, and sensory processing deficits. At the cellular level, Shank3(G/G) mice also exhibit impaired hippocampal excitatory transmission and plasticity as well as changes in baseline NMDA receptor-mediated synaptic responses. This work identifies clear alterations in synaptic function and behavior in a novel, genetically accurate mouse model of autism mimicking an autism-associated insertion mutation. Furthermore, these findings lay the foundation for future studies aimed to validate and study region-selective and temporally selective genetic reversal studies in the Shank3(G/G) mouse that was engineered with such future experiments in mind.
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http://dx.doi.org/10.1523/JNEUROSCI.3125-14.2015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4571502PMC
July 2015

Perceived frailty and measured frailty among adults undergoing hemodialysis: a cross-sectional analysis.

BMC Geriatr 2015 Apr 24;15:52. Epub 2015 Apr 24.

Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD, USA.

Background: Frailty, a validated measure of physiologic reserve, predicts adverse health outcomes among adults with end-stage renal disease. Frailty typically is not measured clinically; instead, a surrogate-perceived frailty-is used to inform clinical decision-making. Because correlations between perceived and measured frailty remain unknown, the aim of this study was to assess their relationship.

Methods: 146 adults undergoing hemodialysis were recruited from a single dialysis center in Baltimore, Maryland. Patient characteristics associated with perceived (reported by nephrologists, nurse practitioners (NPs), or patients) or measured frailty (using the Fried criteria) were identified using ordered logistic regression. The relationship between perceived and measured frailty was assessed using percent agreement, kappa statistic, Pearson's correlation coefficient, and prevalence of misclassification of frailty. Patient characteristics associated with misclassification were determined using Fisher's exact tests, t-tests, or median tests.

Results: Older age (adjusted OR [aOR] = 1.36, 95%CI:1.11-1.68, P = 0.003 per 5-years older) and comorbidity (aOR = 1.49, 95%CI:1.27-1.75, P < 0.001 per additional comorbidity) were associated with greater likelihood of nephrologist-perceived frailty. Being non-African American was associated with greater likelihood of NP- (aOR = 5.51, 95%CI:3.21-9.48, P = 0.003) and patient- (aOR = 4.20, 95%CI:1.61-10.9, P = 0.003) perceived frailty. Percent agreement between perceived and measured frailty was poor (nephrologist, NP, and patient: 64.1%, 67.0%, and 55.5%). Among non-frail participants, 34.4%, 30.0%, and 31.6% were perceived as frail by a nephrologist, NP, or themselves. Older adults (P < 0.001) were more likely to be misclassified as frail by a nephrologist; women (P = 0.04) and non-African Americans (P = 0.02) were more likely to be misclassified by an NP. Neither age, sex, nor race was associated with patient misclassification.

Conclusions: Perceived frailty is an inadequate proxy for measured frailty among patients undergoing hemodialysis.
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http://dx.doi.org/10.1186/s12877-015-0051-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4428253PMC
April 2015
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