Publications by authors named "Rajiv P Reddy"

11 Publications

  • Page 1 of 1

Triggered Electromyography is a Useful Intraoperative Adjunct to Predict Postoperative Neurological Deficit Following Lumbar Pedicle Screw Instrumentation.

Global Spine J 2021 May 20:21925682211018472. Epub 2021 May 20.

Department of Neurological Surgery, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Study Design: Systematic review and meta-analysis.

Objectives: Malposition of pedicle screws during instrumentation in the lumbar spine is associated with complications secondary to spinal cord or nerve root injury. Intraoperative triggered electromyographic monitoring (t-EMG) may be used during instrumentation for early detection of malposition. The association between lumbar pedicle screws stimulated at low EMG thresholds and postoperative neurological deficits, however, remains unknown. The purpose of this study is to assess whether a low threshold t-EMG response to lumbar pedicle screw stimulation can serve as a predictive tool for postoperative neurological deficit.

Methods: The present study is a meta-analysis of the literature from PubMed, Web of Science, and Embase identifying prospective/retrospective studies with outcomes of patients who underwent lumbar spinal fusion with t-EMG testing.

Results: The total study cohort consisted of 2,236 patients and the total postoperative neurological deficit rate was 3.04%. 10.78% of the patients incurred at least 1 pedicle screw that was stimulated below the respective EMG alarm threshold intraoperatively. The incidence of postoperative neurological deficits in patients with a lumbar pedicle screw stimulated below EMG alarm threshold during placement was 13.28%, while only 1.80% in the patients without. The pooled DOR was 10.14. Sensitivity was 49% while specificity was 88%.

Conclusions: Electrically activated lumbar pedicle screws resulting in low t-EMG alarm thresholds are highly specific but weakly sensitive for new postoperative neurological deficits. Patients with new postoperative neurological deficits after lumbar spine surgery were 10 times more likely to have had a lumbar pedicle screw stimulated at a low EMG threshold.
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http://dx.doi.org/10.1177/21925682211018472DOI Listing
May 2021

Diagnostic Accuracy of SSEP Changes during Lumbar Spine Surgery for Predicting Postoperative Neurological Deficit: A Systematic Review and Meta-Analysis.

Spine (Phila Pa 1976) 2021 May 6. Epub 2021 May 6.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA.

Study Design: This study is a meta-analysis of prospective and retrospective studies identified in PubMed, Web of Science, and Embase with outcomes of patients who received intraoperative SSEP monitoring during lumbar spine surgery.

Objective: The objective of this study is to determine the diagnostic accuracy of intraoperative lower extremity (LE) SSEP changes for predicting postoperative neurological deficit. As a secondary analysis, we evaluated three subtypes of intraoperative SSEP changes: reversible, irreversible, and total signal loss.

Summary Of Background Data: Lumbar decompression and fusion surgery can treat lumbar spinal stenosis and spondylolisthesis but carry a risk for nerve root injury. Published neurophysiological monitoring guidelines provide no conclusive evidence for the clinical utility of intraoperative somatosensory evoked potential (SSEP) monitoring during lumbar spine surgery.

Methods: A systematic review was conducted to identify studies with outcomes of patients who underwent lumbar spine surgeries with intraoperative SSEP monitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated and presented with forest plots and a summary receiver operating characteristic (ROC) curve.

Results: The study cohort consisted of 5,607 patients. All significant intraoperative SSEP changes had a sensitivity of 44% and specificity of 97% with a DOR of 22.13 (95% CI, 11.30-43.34). Reversible and irreversible SSEP changes had sensitivities of 28% and 33% and specificities of 97% and 97%, respectively. The DORs for reversible and irreversible SSEP changes were 13.93 (95% CI, 4.60-40.44) and 57.84 (95% CI, 15.95-209.84), respectively. Total loss of SSEPs had a sensitivity of 9% and specificity of 99% with a DOR of 23.91 (95% CI, 7.18-79.65).

Conclusion: SSEP changes during lumbar spine surgery are highly specific but moderately sensitive for new postoperative neurological deficits. Patients who had postoperative neurological deficit were 22 times more likely to have exhibited intraoperative SSEP changes.Level of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000004099DOI Listing
May 2021

Conflict of interest disclosure in orthopaedic and general surgical trauma literature.

Injury 2021 Mar 7. Epub 2021 Mar 7.

Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 1010, Pittsburgh, PA 15213, United States. Electronic address:

Significance: Financial relationships between industry and physicians are a key aspect for the advancement of surgical practice and training, but these relationships also result in a conflict of interest with respect to research. Financial payments to physicians are public within the United States in the Open Payments Database, but the rate of accurate financial disclosure of payments has not previously been studied in trauma surgery publications.

Objective: To determine the rate of accurate financial disclosure in major surgical trauma journals compared with the Open Payments Database.

Materials And Methods: The names of all authors publishing in The Journal of Orthopaedic Trauma, Injury, and The Journal of Trauma and Acute Care Surgery between 2015 and 2018 were obtained from MEDLINE. Non-physicians, physicians outside of the United States, physicians without payments in the Open Payments Database, and physicians with payments types of only "Food and Drink" were excluded. Financial disclosure statements were obtained from the journal websites and manually compared against Open Payments Database entries the year prior to submission and during the year of submission up until 3 months prior to publication for each individual physician. Main outcomes were accuracy of disclosure published with each article, total amount of payments received (disclosure or undisclosed), surgical subspecialty of the reporting physician. Statistical comparisons were made using Chi-square testing with significance defined as p<0.05.

Results: Between 2015 and 2018, 5070 articles were published involving 28,948 authors. 2945 authors met inclusion criteria. 490 authors accurately disclosed their financial relationships with industry (16.6%). The median value of undisclosed payments was $22,140 [IQR $6465, $77,221] which was significantly less than the medial value of disclosed payment of $66,433 [IQR $24,624, $161,886], p<0.001 Orthopaedic surgeons disclosed at a higher rate (26.3%, 479/1818) than general surgeons (4.8%, 47/971), p<0.001.

Conclusions: Physician-industry relationships are key for advancing surgical practice and providing training to physicians. These relationships are not inherently unethical, but there is consistently high inaccuracy of financial disclosure across multiple trauma surgery journals which may indicate the need for further education on financial disclosures during surgical training or active obtainment of publicly available financial disclosures by journals.
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http://dx.doi.org/10.1016/j.injury.2021.03.011DOI Listing
March 2021

Repair of high-grade partial thickness supraspinatus tears after surgical completion of the tear have a lower retear rate when compared to full-thickness tear repair.

Knee Surg Sports Traumatol Arthrosc 2021 Mar 8. Epub 2021 Mar 8.

Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA.

Purpose: High-grade partial thickness rotator cuff tears (i.e., those involving at least 50% of the tendon thickness) are especially challenging to treat and various treatment strategies have been described. Prior studies have demonstrated equivalent outcomes between in situ tear fixation and tear completion repair techniques. However, it is unknown how repair of completed high-grade partial thickness tears to full tears compares to repair of full-thickness tears. The purpose of this study was to compare clinical outcome measures at least 1 year postoperatively between patients who had completion of a high-grade partial thickness supraspinatus tear to a full-thickness tear (PT) and those who had an isolated full-thickness supraspinatus tear (FT). The hypothesis of this study was equivalent retear rates as well as equivalent clinical and patient-reported outcomes between the two groups.

Methods: A retrospective review of 100 patients who underwent isolated arthroscopic supraspinatus repair between 2013 and 2018 with a minimum of 1 year follow-up was performed. Patients were separated into two groups based on their treatment: 56 had completion of a partial thickness supraspinatus tear to full-thickness tear with repair (PT) and 44 had isolated full-thickness supraspinatus repairs (FT). The primary outcome was rotator cuff retear, which was defined as a supraspinatus retear requiring revision repair. Secondary outcomes were patient-reported outcome measures (PROs) including visual analog pain scale (VAS) and subjective shoulder value (SSV), range of motion (ROM) and strength in forward flexion (FF), external rotation (ER), and internal rotation (IR).

Results: There was a significantly lower rate of retear between the PT versus FT groups (3.6% vs. 16.3%, p = 0.040). There were no significant differences between groups for all PROs, all ROM parameters, and all strength parameters (all n.s.).

Discussion: The data from this study demonstrated that the PT group had a significantly lower retear rate at 1 year follow-up than the FT group, while PROs, ROM, and strength were similar between the two groups. Patients with PT supraspinatus tears can have excellent outcomes, equivalent to FT tears, after completion of the tear, and subsequent repair with low retear rates. These findings may aid the treating surgeon when choosing between in situ fixation of the PT supraspinatus tear or completion of the tear and subsequent repair, as it allows the treating surgeon to choose the procedure based on comfort and experience level.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1007/s00167-021-06524-9DOI Listing
March 2021

What is the predictive value of intraoperative somatosensory evoked potential monitoring for postoperative neurological deficit in cervical spine surgery?-a meta-analysis.

Spine J 2021 04 16;21(4):555-570. Epub 2021 Jan 16.

Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Electronic address:

Background Context: Cervical decompression and fusion surgery remains a mainstay of treatment for a variety of cervical pathologies. Potential intraoperative injury to the spinal cord and nerve roots poses nontrivial risk for consequent postoperative neurologic deficits. Although neuromonitoring with intraoperative somatosensory evoked potentials (SSEPs) is often used in cervical spine surgery, its therapeutic value remains controversial.

Purpose: The purpose of the present study was to evaluate whether significant SSEP changes can predict postoperative neurologic complications in cervical spine surgery. A subgroup analysis was performed to compare the predictive power of SSEP changes in both anterior and posterior approaches.

Study Design: The present study was a meta-analysis of the literature from PubMed, Web of Science, and Embase to identify prospective/retrospective studies with outcomes of patients who underwent cervical spine surgeries with intraoperative SSEP monitoring.

Patient Sample: The total cohort consisted of 7,747 patients who underwent cervical spine surgery with intraoperative SSEP monitoring.

Methods: Inclusion criteria for study selection were as follows: (1) prospective or retrospective cohort studies, (2) studies conducted in patients undergoing elective cervical spine surgery not due to aneurysm, tumor, or trauma with intraoperative SSEP monitoring, (3) studies that reported postoperative neurologic outcomes, (4) studies conducted with a sample size ≥20 patients, (5) studies with only adult patients ≥18 years of age, (6) studies published in English, (7) studies inclusive of an abstract.

Outcome Measures: The sensitivity, specificity, diagnostic odds ratio (DOR), and likelihood ratios of overall SSEP changes, reversible SSEP changes, irreversible SSEP changes, and SSEP loss for predicting postoperative neurological deficit were calculated.

Results: The total rate of postoperative neurological deficits was 2.50% (194/7,747) and the total rate of SSEP changes was 7.36% (570/7,747). The incidence of postoperative neurological deficit in patients with intraoperative SSEP changes was 16.49% (94/570) while only 1.39% (100/7,177) in patients without. All significant intraoperative SSEP changes had a sensitivity of 46.0% and specificity of 96.7% with a DOR of 27.32. Reversible and irreversible SSEP changes had sensitivities of 17.7% and 37.1% and specificities of 97.5% and 99.5%, respectively. The DORs for reversible and irreversible SSEP changes were 9.01 and 167.90, respectively. SSEP loss had a DOR of 51.39, sensitivity of 17.3% and specificity 99.6%. In anterior procedures, SSEP changes had a DOR of 9.60, sensitivity of 34.2%, and specificity of 94.7%. In posterior procedures, SSEP changes had a DOR of 13.27, sensitivity of 42.6%, and specificity of 94.0%.

Conclusions: SSEP monitoring is highly specific but weakly sensitive for postoperative neurological deficit following cervical spine surgery. The analysis found that patients with new postoperative neurological deficits were nearly 27 times more likely to have had significant intraoperative SSEP change. Loss of SSEP signals and irreversible SSEP changes seem to indicate a much higher risk of injury than reversible SSEP changes.
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http://dx.doi.org/10.1016/j.spinee.2021.01.010DOI Listing
April 2021

Meta-Analysis of Perioperative Stroke and Mortality in CABG Patients With Carotid Stenosis.

Neurologist 2020 Sep;25(5):113-116

Departments of Neurological Surgery.

Background: Coronary artery bypass grafting (CABG) is a proven approach in the treatment of coronary heart disease, but the surgery has several complications, including stroke and death. Though it has been established that perioperative stroke is associated with higher rates of long-term mortality, the relationship between stroke and mortality in the perioperative period has not yet been systematically examined.

Methods: Online databases of peer-reviewed literature were searched to retrieve articles concerning mortality and stroke after CABG in patients with carotid stenosis. Six studies (n=3786) were included for analysis. This study was conducted at a single University hospital system, University of Pittsburgh Medical Center, on patients who underwent CABG. The data obtained from peer-reviewed literature originated from several sources, primarily single institution hospitals.

Results: Consistent with current literature, the incidence of stroke in CABG patients with significant carotid stenosis was 2.1%. Data were further analyzed to generate a summary odds ratio of stroke-related mortality after CABG, which showed that patients who died within 30 days of CABG were 7.3 times more likely to have had a perioperative stroke (95% confidence interval, 4.1-13.2). The 30-day mortality rate among perioperative stroke victims was 14.4% versus 2.3% for nonstroke patients.

Conclusions: Together, these data suggest an association between stroke and mortality in the perioperative period in patients undergoing CABG, demonstrating a need for improved monitoring, screening, and treatment of stroke before, during, and shortly after surgery.
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http://dx.doi.org/10.1097/NRL.0000000000000277DOI Listing
September 2020

Diagnostic accuracy of various EEG changes during carotid endarterectomy to detect 30-day perioperative stroke: A systematic review.

Clin Neurophysiol 2020 07 23;131(7):1508-1516. Epub 2020 Apr 23.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Electronic address:

Objectives: We assessed whether significant intraoperative electroencephalography (EEG) changes have predictive value for perioperative stroke within 30 days after carotid endarterectomy (CEA) procedures for carotid stenosis (CS) patients. We also assessed the diagnostic accuracy of various EEG changes in predicting perioperative stroke.

Methods: We searched databases for reports with outcomes of CS patients who underwent CEA with intraoperative EEG monitoring. We calculated the sensitivity, specificity, and diagnostic odds ratio (DOR) of EEG changes for predicting perioperative stroke. Sensitivity and specificity were presented with forest plots and a summary receiver operating characteristic (ROC) curve.

Results: The meta-analysis included 10,672 patients. Intraoperative EEG changes predicted 30-day stroke with a sensitivity of 46% (95% CI, 38-54%) and specificity of 86% (95% CI, 83-88%). The estimated DOR was 5.79 (95% CI, 3.86-8.69). The estimated DOR for reversible and irreversible EEG changes were 8.25 (95% CI, 3.34-20.34) and 70.84 (95% CI, 36.01-139.37), respectively.

Conclusion: Intraoperative EEG changes have high specificity but modest sensitivity for predicting perioperative stroke following CEA. Patients with irreversible EEG changes are at high risk for perioperative stroke.

Significance: Intraoperative EEG changes can help surgeons predict the risk of perioperative stroke for CS patients following CEA.
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http://dx.doi.org/10.1016/j.clinph.2020.03.037DOI Listing
July 2020

Long-term cognitive decline and mortality after carotid endarterectomy.

Clin Neurol Neurosurg 2020 07 6;194:105823. Epub 2020 Apr 6.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Electronic address:

Objectives: To date no studies have evaluated long term cognitive decline after carotid endarterectomy (CEA). We evaluated whether participants who had CEA were at increased risk of cognitive decline over participants who didn't undergo CEA.

Patients And Methods: The patients in the study were participants in the Cardiovascular Health Study (CHS), a study of 5201 men and women over the age of 65 who were recruited from four communities (Pittsburgh, Pennsylvania; Sacramento, California; Winston-Salem, North Carolina; Hagerstown, Maryland) in 1988-89. The outcomes measured were 1) Decline in 3MSE and digit symbol substitution test (DSST) scores after CEA compared to before CEA. 2) All-cause mortality in CHS cohort among participants who did and did not have CEA.

Results: CEA patients had significantly greater annual decrease in the DSST scores -2.43 (SD 4.21) compared to those who did not have a CEA -1.1 (SD 2.57) (p < 0.001) but this was not seen in the 3MSE scores. CEA patients had increased the risk of decline in DSST (OR 2.41, 95 % CI 1.49, 3.88) and 3MSE (OR 2.17, 95 % CI 1.35, 3.48) scores after adjusting for age, gender, race and educational status. CEA was associated with all-cause mortality in the long term with a HR of 2.72 (95 % CI 2.22, 3.34) after adjusting for covariates. Participants with lower baseline 3MSE scores HR 1.39 (1.27, 1.51), lower DSST scores <34 HR 1.69(1.54, 1.85) were more likely deceased.

Conclusions: CEA patients are at increased risk of lower scores on 3MSE and DSST testing in the long term. Mortality in the CHS cohort was higher in participants who underwent CEA. Further, lower 3MSE and DSST scores increased the risk of mortality.
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http://dx.doi.org/10.1016/j.clineuro.2020.105823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871212PMC
July 2020

Relaxin reverses maladaptive remodeling of the aged heart through Wnt-signaling.

Sci Rep 2019 12 6;9(1):18545. Epub 2019 Dec 6.

Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15261, USA.

Healthy aging results in cardiac structural and electrical remodeling that increases susceptibility to cardiovascular diseases. Relaxin, an insulin-like hormone, suppresses atrial fibrillation, inflammation and fibrosis in aged rats but the mechanisms-of-action are unknown. Here we show that relaxin treatment of aged rats reverses pathological electrical remodeling (increasing Nav1.5 expression and localization of Connexin43 to intercalated disks) by activating canonical Wnt signaling. In isolated adult ventricular myocytes, relaxin upregulated Nav1.5 (EC = 1.3 nM) by a mechanism inhibited by the addition of Dickkopf-1. Furthermore, relaxin increased the levels of connexin43, Wnt1, and cytosolic and nuclear β-catenin. Treatment with Wnt1 or CHIR-99021 (a GSK3β inhibitor) mimicked the relaxin effects. In isolated fibroblasts, relaxin blocked TGFβ-induced collagen elevation in a Wnt dependent manner. These findings demonstrate a close interplay between relaxin and Wnt-signaling resulting in myocardial remodeling and reveals a fundamental mechanism of great therapeutic potential.
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http://dx.doi.org/10.1038/s41598-019-53867-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6897890PMC
December 2019

Association between perioperative stroke and 30-day mortality in carotid endarterectomy: A meta-analysis.

Clin Neurol Neurosurg 2019 06 1;181:44-51. Epub 2019 Apr 1.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Electronic address:

Objectives: Perioperative stroke is a known complication of carotid endarterectomy (CEA) for patients with symptomatic and asymptomatic carotid stenosis. The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) has shown that stroke following CEA is associated with nearly a 3-fold increase in the 4-year mortality compared to patients without such an event. However, no studies to date can establish whether the stroke was the cause of the short term mortality. Thus, our objective is to evaluate if perioperative stroke after CEA increases the risk of 30-day mortality.

Patients And Methods: We performed a meta-analysis of the literature from PubMed and the World Science Database on studies reporting perioperative strokes and 30-day mortality in symptomatic and asymptomatic CEA patients. 3400 articles were retrieved, and abstracts were further screened using the inclusion criteria to obtain a final set of 83 randomized controlled trials and retrospective/prospective studies.

Results: A total of 123,507 CEA procedures were included among the 83 studies. The 30-day perioperative stroke rate for all included studies was 2.15%. The 30-day all-cause mortality rate was 0.93%. In patients with perioperative strokes, the 30-day mortality rate was found to be 17.01%. Among patients without perioperative strokes, the 30-day mortality rate was much lower at 0.57%. The summary odds ratio of perioperative stroke and 30-day mortality was 39.86 (95% CI, 29.30-54.23, p < 0.001).

Conclusion: Patients with perioperative stroke have an almost 40 times increased risk of 30-day stroke-related mortality. This study highlights the importance of developing a preoperative risk assessment and neuroprotective treatment trial for perioperative stroke.
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http://dx.doi.org/10.1016/j.clineuro.2019.03.028DOI Listing
June 2019

Diagnostic value of somatosensory evoked potential changes during carotid endarterectomy for 30-day perioperative stroke.

Clin Neurophysiol 2018 09 14;129(9):1819-1831. Epub 2018 Jun 14.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Electronic address:

Objectives: Somatosensory evoked potentials (SSEPs) have proven useful as an intraoperative modality to predict perioperative stroke during carotid endarterectomy (CEA). However, the predictive value of SSEPs for predicting stroke 30 days postoperatively remains unclear. The primary objective is to evaluate the efficacy of intraoperative SSEP change in predicting the risk of stroke in the postoperative period beyond 24 h but within 30 days. Our secondary aim is to evaluate the predictive value of each subcategory of SSEP change.

Methods: We performed a meta-analysis of 25 prospective/retrospective studies from PubMed, Web of Science, and Embase regarding SSEP monitoring for postoperative outcomes in symptomatic and asymptomatic CEA patients.

Results: A 8307-patient cohort composed the total sample population, of which 54.17% had symptomatic CS. For SSEP change and stroke greater than 24 h but within 30 days, the diagnostic odds ratio was 8.68. The diagnostic odds ratio was 3.88 for transient SSEP change and stroke; 49.29 for persistent SSEP change and stroke; 36.45 for transient SSEP loss and stroke; and 281.35 for persistent SSEP loss and stroke.

Conclusions: Patients with SSEP changes are at increased risk of perioperative stroke within the entire 30-day period. There is a noticeable step-wise increase in the predicted risk of stroke with the severity of SSEP changes.

Significance: SSEP changes can serve as a predictor for 30-day perioperative stroke during CEA.
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http://dx.doi.org/10.1016/j.clinph.2018.05.018DOI Listing
September 2018