intrathrombus polymer coating deposition: a pilot study of 91 patients undergoing endovascular therapy for acute large vessel stroke. part i: histologic frequency

by:ZHENHUA     2020-09-02
Background due to the use of vascular medical devices, polymer coated embolism is a more and more recognized hospital-like complication.
This phenomenon is associated with various adverse reactions including neuroinflammation, acute ischemia stroke, cerebral hemorrhage, and death.
It is worth noting that the programand device-
The specific risks of such complications are rarely studied.
In this study, we evaluated the internal detectable frequency
Arterial polymer coating stratification in patients with acute ischemia stroke treated with intra-vascular thrombosis due to occlusion of large vessels. Methods Ninety-
A retrospective analysis of the presence of polymer-coated particles in two brain thrombosis resection specimens was performed.
Histological findings were associated with demographic and procedural details and patient outcomes.
Results in 92 cases of extracted thrombosis, 30 cases found evidence of polymer coating deposition (33%).
No correlation was found between the deposition of polymer in the thrombosis and the use of a specific thrombosis removal device (such as a stent collector, a suction catheter, or a guide catheter.
However, the heterogeneous patterns used by devices indicate many of the culprit devices.
In the positive cases, the trend of longer and more passage of thrombosis was noted.
Number of Intrathrombus polymer deposits and measurement of adverse pregnancy outcomes 90-
Modify the Rankin Scale (mRS);
However, the sample size is small, follow-up
Interval upper limit explain. Ninety-
The day results based on mRS May not be able to fully capture the clinical effects of acute and/or delayed polymer complications in the brain.
Conclusion according to the recorded adverse effects of the nervous system, the frequency of polymer particles in the thrombosis indicates the need for consistent test methods and large-scale long-
Relevant endpoints are included to better assess the risk of biological materials and equipment to patients.
Background due to the use of vascular medical devices, polymer coated embolism is a more and more recognized hospital-like complication.
This phenomenon is associated with various adverse reactions including neuroinflammation, acute ischemia stroke, cerebral hemorrhage, and death.
It is worth noting that the programand device-
The specific risks of such complications are rarely studied.
In this study, we evaluated the internal detectable frequency
Arterial polymer coating stratification in patients with acute ischemia stroke treated with intra-vascular thrombosis due to occlusion of large vessels. Methods Ninety-
A retrospective analysis of the presence of polymer-coated particles in two brain thrombosis resection specimens was performed.
Histological findings were associated with demographic and procedural details and patient outcomes.
Results in 92 cases of extracted thrombosis, 30 cases found evidence of polymer coating deposition (33%).
No correlation was found between the deposition of polymer in the thrombosis and the use of a specific thrombosis removal device (such as a stent collector, a suction catheter, or a guide catheter.
However, the heterogeneous patterns used by devices indicate many of the culprit devices.
In the positive cases, the trend of longer and more passage of thrombosis was noted.
Number of Intrathrombus polymer deposits and measurement of adverse pregnancy outcomes 90-
Modify the Rankin Scale (mRS);
However, the sample size is small, follow-up
Interval upper limit explain. Ninety-
The day results based on mRS May not be able to fully capture the clinical effects of acute and/or delayed polymer complications in the brain.
Conclusion according to the recorded adverse effects of the nervous system, the frequency of polymer particles in the thrombosis indicates the need for consistent test methods and large-scale long-
Relevant endpoints are included to better assess the risk of biological materials and equipment to patients.
Introduction 2018 the latest developments of the American Heart Association (AHA)
The management guidelines for patients with acute ischemia stroke have increased the growth trend of intra-vascular treatment of the disease.
DAWN and DEFUSE 3 trials supported the removal of intra-vascular thrombosis in patients with emergency large vascular occlusion within 24 hours of the onset of symptoms, and 1 2 trials significantly expanded the patient\'s acceptance of this operation
These trials mark a significant milestone in stroke management and further expand the number of stroke patients who will be managed globally through vascular devices.
In view of this main trend, the importance of assessing the effectiveness and safety of equipment is increasing.
In recent years, the complications of medical polymer coating have received the attention of pathologists, regulators and industry personnel.
3-9 However, in patients receiving intra-vascular treatment for acute large vessel ischemia stroke, polymer stripping on the coating integrity and equipment surface was not previously assessed.
In this study, we analyzed the frequency of cerebral thrombosis polymer coating deposition retrieved by intra-vascular thrombosis resection in patients with acute large vascular stroke, and characterized the particle features with procedural and clinical data as well
Methods Study design this study was conducted in accordance with the program approved by the Institutional Review Committee of the University of West Virginia.
Since 2011, our institution has been conducting pathological evaluation of brain thrombosis resection specimens.
We searched the pathology database at our facility, at a tertiary care hospital, and at the recently designated comprehensive stroke center for the obtained cerebral thrombosis specimens.
From 2011 to 2017, all cases with cerebral thrombosis specimens that can be retrieved from the archives were included in this retrospective analysis.
Thrombosis resection protocol intra-vascular thrombosis resection is performed in patients with acute ischemia stroke caused by large vessel occlusion according to the conventional institutional protocol, defined as end occlusion of internal jugular artery (ICA-T)
Middle cerebral artery trunk (M1)
, Near-side fork branch (M2)
, Or basal artery (BA).
The choice of equipment for cerebral thrombosis surgery is determined by the therapeutic neurointerventional radiologist.
The extracted thrombosis specimens were submitted for pathology in 10% neutral buffered formaldehyde.
After fixation, treat the specimen overnight, embed it in paraffin, slice it according to the thickness of 5 m, install it on the slide, and dye it with Su Mu essence and Yi Hong (H&E)
And cap.
Two neuropathologists performed histological evaluation of the extracted thrombosis. They know nothing about procedures and clinical data. H&E-
The dye preparation of the sample material was evaluated to determine whether there is a foreign body polymer deposition, as described earlier (figure 1).
5 10-12 scan the human tissue slide by light mirror at 200x and 600 × magnification for analysis.
Particle count, average and maximum particle crossing
Section area (μm2)
Total particle load (
That is, the total particles crosssectional area)(μm2)
Total thrombosis crossSection area (μm2)
Identified in positive cases.
Data acquisition is a digital tracking of particle and thrombosis samples by two neuropathologists using Nikon microscope solution imaging software (NIS-
Element AR version 4. 30. 01)(figure 2).
Download the new tabDownload powerpoint figure 1 The histological appearance of thrombosis and coating deposition. (A)
Thrombosis without polymer particles only showed eos blood and protein products. (B)
Thrombosis with embedded coated particles, visualized as non-
Measure the refractive parent alkali Foreign Body> 100 µm in the maximum size. (C)
There are> 100 thrombosis deposited by the dispersion coating.
Boxed area with high power display (insets).
Download the particles of the new tabDownload figureOpen powerpointFigure month.
Coating particles are identified on H & E-Stained slides (A)
, And manually tracked by neuropathologists using Nikon microscope solution imaging software (NIS-
Element AR version 4. 30. 01)
Determine the number and size of particles (B).
The boxed area displays the object count at a higher power (C, D).
The researchers performed a retrospective analysis of procedural techniques, patient demographics, and a review of the results chart, and they did not know anything about tissue pathology data (including the presence or absence of polymer particles in the thrombosis.
Including age, gender, stroke scale of the National Institutes of Health (NIHSS)
Patient Results (death, 90-
Modified Rankin Scale Day, TICI perfusion level)
And recorded the time of stay.
Patients with diabetes, hypertension, high blood fat, atrial fibrillation and smoking history were identified.
In addition, the procedure details, including the duration of the operation, the number of passes through the use of the thrombosis removal device, and the use of the specific device (
Guide wire, guide wire catheter, micro guide tube, suction pump, shutter and/or shutter)were recorded.
Statistical analysis-
The evaluator protocol, because the tissue is the same as the polymer particle to determine the kappa coefficient of Cohen (κ).
Using Mean particle crossover
Assuming the average spherical shape of the particles, the formula V = 4/3 π r3 is used to extrapolate the cross-sectional area, mean radius and diameter of the particles and estimate the mean particle volume.
The presence and dimensional features of coated particles in thrombosis are associated with patient demographics, complications, procedural techniques, and patient outcomes.
All data analysis using JMP Statistics Software V. 11 (
Cary SAS Institute, North Carolina, USA).
Use Fisher\'s precise test of the classification variables (Student\'s t-
Test continuous variables or logistic regression as needed.
The study designed the study to be conducted under an agreement approved by the Institutional Review Committee of the University of West Virginia.
Since 2011, our institution has been conducting pathological evaluation of brain thrombosis resection specimens.
We searched the pathology database at our facility, at a tertiary care hospital, and at the recently designated comprehensive stroke center for the obtained cerebral thrombosis specimens.
From 2011 to 2017, all cases with cerebral thrombosis specimens that can be retrieved from the archives were included in this retrospective analysis.
Thrombosis resection protocol intra-vascular thrombosis resection is performed in patients with acute ischemia stroke caused by large vessel occlusion according to the conventional institutional protocol, defined as end occlusion of internal jugular artery (ICA-T)
Middle cerebral artery trunk (M1)
, Near-side fork branch (M2)
, Or basal artery (BA).
The choice of equipment for cerebral thrombosis surgery is determined by the therapeutic neurointerventional radiologist.
The extracted thrombosis specimens were submitted for pathology in 10% neutral buffered formaldehyde.
After fixation, treat the specimen overnight, embed it in paraffin, slice it according to the thickness of 5 m, install it on the slide, and dye it with Su Mu essence and Yi Hong (H&E)
And cap.
Two neuropathologists performed histological evaluation of the extracted thrombosis. They know nothing about procedures and clinical data. H&E-
The dye preparation of the sample material was evaluated to determine whether there is a foreign body polymer deposition, as described earlier (figure 1).
5 10-12 scan the human tissue slide by light mirror at 200x and 600 × magnification for analysis.
Particle count, average and maximum particle crossing
Section area (μm2)
Total particle load (
That is, the total particles crosssectional area)(μm2)
Total thrombosis crossSection area (μm2)
Identified in positive cases.
Data acquisition is a digital tracking of particle and thrombosis samples by two neuropathologists using Nikon microscope solution imaging software (NIS-
Element AR version 4. 30. 01)(figure 2).
Download the new tabDownload powerpoint figure 1 The histological appearance of thrombosis and coating deposition. (A)
Thrombosis without polymer particles only showed eos blood and protein products. (B)
Thrombosis with embedded coated particles, visualized as non-
Measure the refractive parent alkali Foreign Body> 100 µm in the maximum size. (C)
There are> 100 thrombosis deposited by the dispersion coating.
Boxed area with high power display (insets).
Download the particles of the new tabDownload figureOpen powerpointFigure month.
Coating particles are identified on H & E-Stained slides (A)
, And manually tracked by neuropathologists using Nikon microscope solution imaging software (NIS-
Element AR version 4. 30. 01)
Determine the number and size of particles (B).
The boxed area displays the object count at a higher power (C, D).
The researchers performed a retrospective analysis of procedural techniques, patient demographics, and a review of the results chart, and they did not know anything about tissue pathology data (including the presence or absence of polymer particles in the thrombosis.
Including age, gender, stroke scale of the National Institutes of Health (NIHSS)
Patient Results (death, 90-
Modified Rankin Scale Day, TICI perfusion level)
And recorded the time of stay.
Patients with diabetes, hypertension, high blood fat, atrial fibrillation and smoking history were identified.
In addition, the procedure details, including the duration of the operation, the number of passes through the use of the thrombosis removal device, and the use of the specific device (
Guide wire, guide wire catheter, micro guide tube, suction pump, shutter and/or shutter)were recorded.
Statistical analysis-
The evaluator protocol, because the tissue is the same as the polymer particle to determine the kappa coefficient of Cohen (κ).
Using Mean particle crossover
Assuming the average spherical shape of the particles, the formula V = 4/3 π r3 is used to extrapolate the cross-sectional area, mean radius and diameter of the particles and estimate the mean particle volume.
The presence and dimensional features of coated particles in thrombosis are associated with patient demographics, complications, procedural techniques, and patient outcomes.
All data analysis using JMP Statistics Software V. 11 (
Cary SAS Institute, North Carolina, USA).
Use Fisher\'s precise test of the classification variables (Student\'s t-
Test continuous variables or logistic regression as needed.
Results of Population Studies
Two cases of cerebral thrombosis retrieved from 91 patients were identified in our file to be included in this study.
Patient population and clinical data are summarized in Table 1.
View this table: in 30 of 92 samples of cerebral thrombosis, it is easy to detect demographic and clinical information in 91 patients who underwent histological analysis of intra-vascular thrombosis in acute ischemia stroke33%).
The sediment is characterized by non-parent substrate, particles, plate layer or amorphous, foreign body in thrombosis
Refraction and non-refraction
Polarization, as mentioned earlier (figure 1).
Count of 5 10-12 particles, Cross
As shown in Table 2 and Figure 3, the cross-sectional area, total load, mean and maximum particle diameter and estimated mean volume are variable.
No additional foreign material was found under any circumstances.
The average cross-examination of all 30 positive samples showed particle measurements of more than 100 m2. sectional area; 21 (70%)
Show particles with a maximum diameter of> 50 μm; 16 (53%)
There are particles greater than 10 in quantity and quantity (3%)
Total number of particles in Hada> 100.
The particle count ranges from 1 to 605.
Two experienced neuropathologists conducted an independent review of the sample to determine the presence or absence of polymer particles
Reader agreement (κ=0. 95).
Figure 3 Distribution of mean and maximum granularity (diameter).
View this table: View the quantitative polymer features in 2 30 samples of inline View popupTable and have evidence of polymer deposition in thrombosis. Correlation of intra-thrombosis granules with patient output. Burden of age or gender in granular patients.
Using TICI perfusion scores, no statistically significant correlation was found between particle deposition and patient outcomes, 90-
Mortality is used as the standard of outcome.
There was no significant correlation between polymer stratification and co-morbidity such as diabetes, hypertension, high blood fat, atrial fibrillation and smoking.
The presence of related particles of intra-thrombosis particles and procedure techniques compared to the discovery of polymer-free conditions, the procedure time was longer (
87 + 29 min vs 71 + 48 min, p = 0. 06).
There is also a trend in multiple thrombosis.
There were 20 cases of particulate matter in 55 cases (36. 3%)
Compared with 10 of 37 cases, more than one thrombosis was performed (27%)
Only one pass is required (p=0. 34).
There was no statistically significant correlation between polymer stratification and the use of a specific stent Finder, suction device, catheter or guide wire.
In addition, the use of the bracket finder did not produce larger polymer particles compared to the use of the suction catheter alone.
Table 3 sets out the equipment used in the case of showing evidence of coated particles in the thrombosis.
Study population 90-
Two cases of cerebral thrombosis retrieved from 91 patients were identified in our file to be included in this study.
Patient population and clinical data are summarized in Table 1.
View this table: in 30 of 92 samples of cerebral thrombosis, it is easy to detect demographic and clinical information in 91 patients who underwent histological analysis of intra-vascular thrombosis in acute ischemia stroke33%).
The sediment is characterized by non-parent substrate, particles, plate layer or amorphous, foreign body in thrombosis
Refraction and non-refraction
Polarization, as mentioned earlier (figure 1).
Count of 5 10-12 particles, Cross
As shown in Table 2 and Figure 3, the cross-sectional area, total load, mean and maximum particle diameter and estimated mean volume are variable.
No additional foreign material was found under any circumstances.
The average cross-examination of all 30 positive samples showed particle measurements of more than 100 m2. sectional area; 21 (70%)
Show particles with a maximum diameter of> 50 μm; 16 (53%)
There are particles greater than 10 in quantity and quantity (3%)
Total number of particles in Hada> 100.
The particle count ranges from 1 to 605.
Two experienced neuropathologists conducted an independent review of the sample to determine the presence or absence of polymer particles
Reader agreement (κ=0. 95).
Figure 3 Distribution of mean and maximum granularity (diameter).
View this table: View the quantitative polymer features in 2 30 samples of inline View popupTable and have evidence of polymer deposition in thrombosis. Correlation of intra-thrombosis granules with patient output. Burden of age or gender in granular patients.
Using TICI perfusion scores, no statistically significant correlation was found between particle deposition and patient outcomes, 90-
Mortality is used as the standard of outcome.
There was no significant correlation between polymer stratification and co-morbidity such as diabetes, hypertension, high blood fat, atrial fibrillation and smoking.
The presence of related particles of intra-thrombosis particles and procedure techniques compared to the discovery of polymer-free conditions, the procedure time was longer (
87 + 29 min vs 71 + 48 min, p = 0. 06).
There is also a trend in multiple thrombosis.
There were 20 cases of particulate matter in 55 cases (36. 3%)
Compared with 10 of 37 cases, more than one thrombosis was performed (27%)
Only one pass is required (p=0. 34).
There was no statistically significant correlation between polymer stratification and the use of a specific stent Finder, suction device, catheter or guide wire.
In addition, the use of the bracket finder did not produce larger polymer particles compared to the use of the suction catheter alone.
Table 3 sets out the equipment used in the case of showing evidence of coated particles in the thrombosis.
To discuss the microparticle embolism caused by the use of an in-vessel device is an increasingly recognized complication that has the potential to have significant unexpected neurological adverse effects.
A sub-optimal protocol for the manufacture, packaging, storage, preparation and/or use of the equipment by the operator may produce particles and potential sources may include environmental materials (
Dust, gauze)
Natural organization (
Components of the heart muscle or blood vessel wall that fall off)
And/or inherent device materials such as device coating.
Due to the complex reactions in vivo, different particle components are worth further study, as each component may have unique organ effects and diagnostic challenges.
Although the use of vascular instruments is increasing, the systematic analysis of the frequency and features of hospital-like particles, including the risk of polymer coating, is relatively small.
In this investigation
Cerebral thrombosis III (
30 of 92 samples)
It was found that mechanically recovered from patients with acute large vascular ischemia stroke contained undressed device coated particles.
As far as we know, this is the first survey to report the frequency of the device coating particles in patients with instrument stroke.
The results of this study add to the evidence that intra-vascular polymer coating embolism is common in various intra-vascular procedures.
2015 autopsy surveys of 136 patients showed that 13% of adult hospital dead who had different cardiovascular interventions had polymer coating deposits in the brain, lungs and/or heart;
This post-mortem study was not intended to assess the equipment. or procedure-
Specific frequency.
In a separate analysis, Grundeken et al. evaluated the frequency of polymer coating stratification associated with cardiac vascular reconstruction in patients treated with acute myocardial ischemia.
7 retrospective analysis showed that 92 of the 205 patients with coronary artery thrombosis had polymer particles (45%)
And attributed to a variety of heart wire coating.
In this same study, the heart muscle of patients undergoing coronary intervention was also evaluated on post-mortem histology and it was found that 4 of the 40 patients had distal polymer embolus (10%).
A rare prospective study evaluated the polymer coating stratification of live patients undergoing catheter heart valve and ablation surgery and showed that in these cases, the stratification rate ranged from 30% to 86%.
13-16 while the evaluation of the frequency and clinical effects of polymer coating reactions in live patients presents complex challenges, existing information on coating risks requires continued investigation and establishment of equipment evaluation and testing
The potential sequelae of the embolism polymer coating in the brain, including death, ischemia and/or bleeding stroke, chronic neuroinflammation, headache, constitutional symptoms, seizures and cognitive dysfunction, have been previously reported.
4-6 10-12 17-26, while steroid and immunotherapy have proven beneficial in some patients developing inflammatory response
There is no systematic study of the results of the terminology, the subclinical inflammatory response, and the effects of co-diseased small vascular diseases.
In addition, the chronic neuroinflammatory response in some patients has been ongoing for several years and is associated with immune suppression
Related adverse reactions, white matter, loss of brain capacity and secondary disability.
It is worth noting that these and other potential long-term
Terms for tissue changes and organ effects do not pass the report 90-
A day of torture.
The appropriate pre-clinical and clinical test methods for device-coated embolism are still uncertain, in part related to the complex morphology and distribution of polymer particles.
This hinders understanding of the comparative risk of coating for specific vascular medical devices.
Current surveys and other recent studies13-16 suggest that it is feasible to quantitatively evaluate polymer particles in live patients using a common method, although attention should be paid to the advantages and disadvantages of the test methods used.
By performing routine histological analysis of the extracted thrombosis, particle analysis is possible without increasing the clinical risk of the patient.
In addition, the intra-vascular tissue of evacuation is analyzed (
Thrombosis resection and filtrationSpecimen based)
It is possible to generate greater sensitivity than downstream tissue sampling and provide greater insight into the auscultation procedure.
However, the histological test method was associated with false Yin because random tissue sampling and evaluation of a single 5 µm thick slice only allowed screening of patient specimens with a limited portion.
The samples of thrombosis assessed in this study were not subjected to volumetric analysis, nor did they perform a complete analysis (figure 4).
In addition, in the current study, it is not possible to evaluate the coated fragments released into the blood and deposited in the downstream site.
As a result, this technique is not able to assess the distal tissue response, including the sequelae of ischemia and inflammation, requiring invasive biopsy or post-mortem analysis.
The identification of specific polymer chemistry is not described in this report and additional chemical particle analysis is required (
For example, infrared or Raman spectra are transformed by Fourier transform).
Since of the 30 positive thrombosis samples tested here, none of the samples had a prospective diagnosis of particle deposition, it is necessary to detect polymer deposition in human tissues to understand this complication, to suspect indicators, targeted organization and high
Dynamic micro-analysis 4;
These factors will have an impact on the test sensitivity.
Nevertheless, good international
In this retrospective analysis, the reader is consistent.
Limitations of the test method used to download figure 4 in the new tabDownload powerpoint.
In this study, a single random crossover
The presence of coated particles was evaluated.
As shown in the schematic diagram, limited sampling and random slices may result in false negative and undernegative
Particle load report.
The detection, quantification and reporting of polymer particles in tissue specimens requires a consistent approach, which will help to perform a more meaningful analysis of the complications of the Cork coating.
As summarized here, different approaches can be taken to quantify and report particle loads (ie, one-
Two-dimensional
Three dimensional
Particle size analysis
Maximum measurement 1-
The size length cannot fully capture the particle size and load, nor can it obtain the actual particle volume by evaluation of a single histological slice.
Although the shape and size of the coated particles vary greatly, the extrapolation particle volume and mean diameter analysis based on the mean spherical shape may be a useful technique for estimating and reporting the polymer burden in the actual patient sample, for comparison of in vitro and regulatory device testing, more information may be provided. Device-
After simulation or real use, it is best to measure the production of specific particles by in vitro and in vitro device surface analysis
World Environment.
Although the ability to produce equipment in vivo analysis is limited
Specific information, clinical research is still critical to assess the actual effect and particle load of patients using various devices.
In this study, no correlation was found between polymer stratification and the use of a stent recycler or a specific thrombosis removal device, catheter, or guide wire.
However, due to the sample size and heterogeneous patterns used by the device, this study was not designed or driven to make any definitive conclusions about the particular device
Related risks.
It is now recognized that many devices contribute to the production of intra-vascular polymer particles, and the results of this study further indicate the need for a new examination method for coating devices for clinical use in the vessels.
Although no correlation between polymer stratification and poor patient outcomes was found in this survey, 90-
DaymRS alone is not an appropriate measure to assess clinical significance.
For future studies, more standardized clinical test methods and formal reports of particle size, load and intra-vascular effects have the potential to influence future guidance on biological material selection and standards.
4 27 conclusion micro-embolism of common coated particles in vascular surgery;
However, there is insufficient quantitative study of the frequency and risk of associated complications.
In addition, existing evidence suggests that the current pre-clinical simulation use test does not fully predict the coating performance of devices in practical applicationsworld settings.
4 in order to better understand the safety and integrity of equipment surface materials and procedural techniques, an appropriate endpoint must be established and incorporated into pre-clinical testing and clinical trials to evaluate equipment manufacturing and biological materials
The FDA has acknowledged the importance of expanding pre-clinical in vitro safety testing, but further clinical studies are needed, which may drive pre-clinical testing requirements and industry standards. 4 Large-scale, multi-
Director of medical equipment and organization registrationterm follow-
Up will help to characterize and compare the effects of specific biological materials and equipment for patients on site, and will help to identify source coatings.
While over time, there has been a general increase in awareness of the importance of research on microparticles, formal pre-clinical and clinical guidelines, as well as consensus proposals for testing, interpretation, and lack of reporting, it remains an important priority area for determining the safety of comparison procedures and equipment.
View this table: View the inline View pop-up table 3 devices used in cases where there is evidence of an in-thrombosis coating
Thrombosis was removed 6 to 24 hours after stroke and deficit did not match myocardial infarction.
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RIM, foot-bottom contributor: research design and conception, data collection, data analysis, manuscript preparation, approval of the final version of the manuscript.
ATR: research design, data collection, data analysis, final version of the manuscript approval.
OES and oe: data collection, data analysis and approval of the final version of the manuscript. Funding RIM (Rashi I Mehta)
Funded by the National Institute of General Medicine of the National Institutes of Health (5U54GM104942-03). RIM (Rupal I Mehta)
Funded by the National Institute of Neurological Diseases and Stroke (K08NS089830).
Competitive interest ATR is a consultant to Stryker Corporation.
Uncommissioned source and peer review;
External peer review.
In this work, it was introduced at the SNIS 15 annual meeting in San Francisco, California.
Patients are not required to agree to release.
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