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Schmidt A, Sigl-Kraetzig M, Richter H, Vogler T, Tomschi F, Hilberg T. Structural alterations and pain perception at the ankle joint in patients with haemophilia. Haemophilia 2024; 30:827-835. [PMID: 38600680 DOI: 10.1111/hae.15011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/04/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Patients with haemophilia (PwH) suffer from chronic pain due to joint alterations induced by recurring haemorrhage. OBJECTIVES This study aimed to investigate the relationship between structural alterations and pain perception at the ankle joint in PwH. PATIENTS/METHODS Ankle joints of 79 PwH and 57 healthy controls (Con) underwent ultrasound examination (US) and assessment of pain sensitivity via pressure pain thresholds (PPT). US discriminated between joint activity (synovitis) and joint damage (cartilage and/or bone degeneration) applying the HEAD-US protocol. Based on US-findings, five subgroups were built: PwH with activity/damage, PwH with activity/no damage, PwH with no activity/no damage, controls with activity/no damage and controls with no activity/no damage. RESULTS Joint activity and joint damage were significantly increased in ankles of PwH compared to Con (p ≤.001). Subgroup analysis revealed that structural alterations negatively impact pain perception. This is particularly evident when comparing PwH with both activity/damage to PwH with no activity/no damage at the tibiotalar joint (p = .001). At the fibulotalar joint, no significant differences were observed between PwH subgroups. Further analysis showed that both joint activity and joint damage result in an increase in pain sensitivity (p ≤.001). CONCLUSION The data suggest a relation between joint activity, joint damage and pain perception in PwH. Even minor changes due to synovitis appear to affect pain perception, with the effect not intensifying at higher levels of inflammation. In terms of joint damage, severe degeneration leads to a sensitised pain state most robustly, whereas initial changes do not seem to significantly affect pain perception.
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Affiliation(s)
- Alexander Schmidt
- Department of Sports Medicine, University of Wuppertal, Wuppertal, Germany
| | | | | | - Tim Vogler
- Center for Sports Medicine, Münster, Germany
| | - Fabian Tomschi
- Department of Sports Medicine, University of Wuppertal, Wuppertal, Germany
| | - Thomas Hilberg
- Department of Sports Medicine, University of Wuppertal, Wuppertal, Germany
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2
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Cain AA, Davis GJ, Davis S, Bastian RP, Marquez V, Probasco H, Desantis E. Infrared thermography as a diagnostic tool to detect cranial cruciate ligament deficiency in dogs. CANADIAN JOURNAL OF VETERINARY RESEARCH = REVUE CANADIENNE DE RECHERCHE VETERINAIRE 2023; 87:290-296. [PMID: 37790270 PMCID: PMC10542954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/08/2023] [Indexed: 10/05/2023]
Abstract
Cranial cruciate ligament (CCL) disease is the leading cause of canine lameness. Diagnosis is based on physical examination and diagnostic imaging findings. Limitations of diagnostic modalities, including patient temperament, cost, availability, and need for general anesthesia, preclude their use for many patients. Infrared thermography is an easy, non-invasive diagnostic screening technique with use in both human and veterinary musculoskeletal conditions. The objective of this study was to investigate the utility of infrared thermography to diagnose CCL disease in a large population of client-owned dogs and investigate for correlations between ability of thermography to diagnose CCL deficiency and recorded explanatory factors. A commercial grade thermal imaging camera was used to collect preoperative images of both stifles in 50 dogs with surgically confirmed CCL rupture in one stifle and a normal opposite stifle. The average maximum temperatures of the affected and unaffected stifles were collected from these images and used for statistical analysis. Infrared thermography was not successful in differentiating between CCL-deficient and unaffected stifles in this cohort. No significant differences in average maximal temperature were observed between stifles when comparing to explanatory factors or variables. Use of infrared thermography should not be relied upon to diagnose canine CCL disease.
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Affiliation(s)
- Alison A Cain
- Department of Surgery, Red Bank Veterinary Hospital, Tinton Falls, New Jersey, USA (Cain, Davis G, Davis S); Department of Mathematics (Bastian, Marquez, Probasco) and Department of Biology (Desantis) Monmouth University, West Long Branch, New Jersey, USA
| | - Garrett J Davis
- Department of Surgery, Red Bank Veterinary Hospital, Tinton Falls, New Jersey, USA (Cain, Davis G, Davis S); Department of Mathematics (Bastian, Marquez, Probasco) and Department of Biology (Desantis) Monmouth University, West Long Branch, New Jersey, USA
| | - Spencer Davis
- Department of Surgery, Red Bank Veterinary Hospital, Tinton Falls, New Jersey, USA (Cain, Davis G, Davis S); Department of Mathematics (Bastian, Marquez, Probasco) and Department of Biology (Desantis) Monmouth University, West Long Branch, New Jersey, USA
| | - Richard P Bastian
- Department of Surgery, Red Bank Veterinary Hospital, Tinton Falls, New Jersey, USA (Cain, Davis G, Davis S); Department of Mathematics (Bastian, Marquez, Probasco) and Department of Biology (Desantis) Monmouth University, West Long Branch, New Jersey, USA
| | - Veronica Marquez
- Department of Surgery, Red Bank Veterinary Hospital, Tinton Falls, New Jersey, USA (Cain, Davis G, Davis S); Department of Mathematics (Bastian, Marquez, Probasco) and Department of Biology (Desantis) Monmouth University, West Long Branch, New Jersey, USA
| | - Hollyn Probasco
- Department of Surgery, Red Bank Veterinary Hospital, Tinton Falls, New Jersey, USA (Cain, Davis G, Davis S); Department of Mathematics (Bastian, Marquez, Probasco) and Department of Biology (Desantis) Monmouth University, West Long Branch, New Jersey, USA
| | - Emma Desantis
- Department of Surgery, Red Bank Veterinary Hospital, Tinton Falls, New Jersey, USA (Cain, Davis G, Davis S); Department of Mathematics (Bastian, Marquez, Probasco) and Department of Biology (Desantis) Monmouth University, West Long Branch, New Jersey, USA
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3
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Kawasaki R, Sakata A, Hosoda C, Harada S, Soeda T, Nishida Y, Matsumoto N, Tatsumi K, Nogami K, Yoshimura Y, Shima M. The use of infrared thermography for non-invasive detection of bleeding and musculoskeletal abnormalities in patients with hemophilia: an observational study. Thromb J 2023; 21:70. [PMID: 37381012 DOI: 10.1186/s12959-023-00511-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/05/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND In patients with hemophilia (PwH), bleeding often occurs in joints and muscles, and early detection of hemorrhage is important to prevent the onset and progression of mobility impairment. Complex-Image analysis such as ultrasonography, computed tomography, and magnetic resonance imaging are used to detect bleeding. On the other hand, no simple and rapid method to detect the active bleeding has been reported. Local inflammatory responses occur when blood leaks from damaged vessels, and the temperature at the site of active bleeding could be expected to increase in these circumstances, leading to an increase in surrounding skin temperature. Therefore, the purpose of this study was to investigate whether the measurement of skin temperature using infrared thermography (IRT) can be used as a diagnostic aid to detect active bleeding. METHODS Fifteen PwH (from 6 to 82 years old) complaining of discomfort such as pain were examined. Thermal images were obtained simultaneously at the affected sides and comparable unaffected sides. The average skin temperature of the affected side and of the unaffected side were measured. The temperature differences were calculated by subtracting the average skin temperature at the unaffected side from the affected side. RESULTS In eleven cases with active bleeding, the skin temperature at the affected side was more than 0.3 °C higher (0.3 °C to 1.4 °C) compared to the unaffected side. In two cases without active bleeding, there were no significant differences in skin temperature between the affected and unaffected sides. In two cases with previous rib or thumb bone fracture, the skin temperature at the affected side was 0.3 °C or 0.4 °C lower than that of the unaffected side, respectively. In two cases with active bleeding in which longitudinal evaluation was conducted, the difference in skin temperature decreased after hemostatic treatment. CONCLUSION The analysis of skin temperature deference using IRT was a useful supportive tool to readily assess musculoskeletal abnormalities and bleeding in PwH as well as to determine the success of the hemostatic treatment.
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Affiliation(s)
- Ryohei Kawasaki
- Medicinal Biology of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
- Product Research Department, Medical Affairs Division, Chugai Pharmaceutical Co., Ltd., Yokohama, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Asuka Sakata
- Medicinal Biology of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Chihiro Hosoda
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Suguru Harada
- Medicinal Biology of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
- Product Research Department, Medical Affairs Division, Chugai Pharmaceutical Co., Ltd., Yokohama, Japan
| | - Tetsuhiro Soeda
- Medicinal Biology of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
- Product Research Department, Medical Affairs Division, Chugai Pharmaceutical Co., Ltd., Yokohama, Japan
| | - Yukiko Nishida
- Medicinal Biology of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
- Project Planning and Coordination Department, Translational Research Division, Chugai Pharmaceutical Co., Ltd., Chuo-ku, Japan
| | - Naoki Matsumoto
- Medicinal Biology of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
- Product Research Department, Medical Affairs Division, Chugai Pharmaceutical Co., Ltd., Yokohama, Japan
| | - Kohei Tatsumi
- Medicinal Biology of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Yasushi Yoshimura
- Product Research Department, Medical Affairs Division, Chugai Pharmaceutical Co., Ltd., Yokohama, Japan
| | - Midori Shima
- Medicinal Biology of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan.
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4
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Pain: a neglected symptom in hemophilia. Ann Hematol 2023; 102:947-953. [PMID: 36820905 DOI: 10.1007/s00277-023-05134-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
Repetitive bleeding attacks may cause joint pain and arthropathy in patients with hemophilia (PWH). Despite being a common symptom, pain is not a well-studied topic in this disease. The aim of this cross-sectional, observational study was to assess the frequency and intensity of pain and analyze the success rates ofpain treatment methods. Adult hemophilia patients were included in the study. The Multidimensional Hemophilia Pain Questionnaire (MHPQ) was used to assess pain. In addition to the MHPQ, demographic data were collected. Fifty adult hemophilia patients were included in the study. Thirty-one (62%) of the patients reported pain due to hemophilia in the last year. Twenty-six of them (81.2%) reported pain during bleeding attacks. The most successful pain coping strategy was clotting factor replacement. None of the participants used opioids or adjuvant analgesics. None of them used a physical therapy modality or interventional pain therapy method. While 67.6% of the patients were very dissatisfied or dissatisfied with their global pain treatment, only 16.1% of the patients were satisfied or very satisfied. Patients with higher pain during bleeding episodes were more likely to continue their prophylaxis. There was no significant difference between plasma-derived or recombinant-derived factor prophylaxis in terms of pain complaints. Pain is a frequent and important symptom of hemophilia, but most of the patients are not treated sufficiently. A multidisciplinary approach is needed to improve the life quality of the patients. In addition to successful bleeding prophylaxis, administration of a proper and adequate analgesic regimen and combined physical therapy modalities may decrease pain intensity and prevent the development of arthropathy.
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Mancuso ME, Holstein K, O'Donnell JS, Lobet S, Klamroth R. Synovitis and joint health in patients with haemophilia: Statements from a European e-Delphi consensus study. Haemophilia 2023; 29:619-628. [PMID: 36622258 DOI: 10.1111/hae.14734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/01/2022] [Accepted: 12/14/2022] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Synovitis, a common feature in haemophilia, is triggered by the presence of blood in joints, and represents the first step towards the development of chronic arthropathy. Synovitis may be detected early by means of ultrasound or magnetic resonance imaging scan; clinical joint scores are less sensitive in this setting. Regular long-term prophylaxis with clotting factor concentrates, as primary prophylaxis and tailored to individual needs, has high efficacy in preventing synovitis. In general, higher factor levels lower bleeding risk, but no direct correlation between factor levels and synovitis incidence has been demonstrated. AIM This study aimed to develop an expert consensus relating to the definition, pathophysiology, diagnosis, prevention, follow-up and treatment of synovitis, recognising its relevance for joint health and taking into account existing knowledge gaps. METHODS A Delphi consensus study was designed and performed. An expert group prepared 22 statements based on existing literature; a wider expert panel subsequently voted on these. RESULTS Retention of panellists was high. Four statements required amending and consensus on all statements was achieved after three rounds of voting. CONCLUSION This e-Delphi consensus study addressed the importance of synovitis in joint health of people with haemophilia and highlighted knowledge gaps in this field. Studies on the natural course of synovitis are lacking and the biological mechanisms underlying this process are not yet fully elucidated. While basic and clinical research proceeds in this field, expert consensus can help guide clinicians in their routine clinical practice, and Delphi methodology is often used to produce best-practice guidelines.
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Affiliation(s)
- Maria Elisa Mancuso
- IRCCS Humanitas Research Hospital, Centre for Thrombosis and Haemorrhagic Diseases, Rozzano, Milan, Italy
| | - Katharina Holstein
- Department of Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - James S O'Donnell
- National Coagulation Centre, St. James's Hospital, Dublin, Ireland.,Irish Centre for Vascular Biology, School of Pharmacy and Biomedical Sciences, RCSI, Dublin, Ireland
| | - Sébastien Lobet
- Hematology department, Saint-Luc University Clinics, Avenue Hippocrate 10, Brussels, Belgium.,Neuromusculoskeletal Lab (NMSK), Institute for Experimental and Clinical, Catholic University of Louvain, Avenue Hippocrate, Woluwe-Saint-Lambert, Belgium.,Physical Medicine and Rehabilitation Service, Saint-Luc University Clinics, Avenue Hippocrate 10, Brussels, Belgium
| | - Robert Klamroth
- Vivantes Hospital, Friedrichshain, Berlin, Germany.,Institute of Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
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- IRCCS Humanitas Research Hospital, Centre for Thrombosis and Haemorrhagic Diseases, Rozzano, Milan, Italy
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6
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Lee P, Kim H, Zitouni MS, Khandoker A, Jelinek HF, Hadjileontiadis L, Lee U, Jeong Y. Trends in Smart Helmets With Multimodal Sensing for Health and Safety: Scoping Review. JMIR Mhealth Uhealth 2022; 10:e40797. [PMID: 36378505 PMCID: PMC9709670 DOI: 10.2196/40797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/30/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND As a form of the Internet of Things (IoT)-gateways, a smart helmet is one of the core devices that offers distinct functionalities. The development of smart helmets connected to IoT infrastructure helps promote connected health and safety in various fields. In this regard, we present a comprehensive analysis of smart helmet technology and its main characteristics and applications for health and safety. OBJECTIVE This paper reviews the trends in smart helmet technology and provides an overview of the current and future potential deployments of such technology, the development of smart helmets for continuous monitoring of the health status of users, and the surrounding environmental conditions. The research questions were as follows: What are the main purposes and domains of smart helmets for health and safety? How have researchers realized key features and with what types of sensors? METHODS We selected studies cited in electronic databases such as Google Scholar, Web of Science, ScienceDirect, and EBSCO on smart helmets through a keyword search from January 2010 to December 2021. In total, 1268 papers were identified (Web of Science: 87/1268, 6.86%; EBSCO: 149/1268, 11.75%; ScienceDirect: 248/1268, 19.55%; and Google Scholar: 784/1268, 61.82%), and the number of final studies included after PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) study selection was 57. We also performed a self-assessment of the reviewed articles to determine the quality of the paper. The scoring was based on five criteria: test environment, prototype quality, feasibility test, sensor calibration, and versatility. RESULTS Smart helmet research has been considered in industry, sports, first responder, and health tracking scenarios for health and safety purposes. Among 57 studies, most studies with prototype development were industrial applications (18/57, 32%), and the 2 most frequent studies including simulation were industry (23/57, 40%) and sports (23/57, 40%) applications. From our assessment-scoring result, studies tended to focus on sensor calibration results (2.3 out of 3), while the lowest part was a feasibility test (1.6 out of 3). Further classification of the purpose of smart helmets yielded 4 major categories, including activity, physiological and environmental (hazard) risk sensing, as well as risk event alerting. CONCLUSIONS A summary of existing smart helmet systems is presented with a review of the sensor features used in the prototyping demonstrations. Overall, we aimed to explore new possibilities by examining the latest research, sensor technologies, and application platform perspectives for smart helmets as promising wearable devices. The barriers to users, challenges in the development of smart helmets, and future opportunities for health and safety applications are also discussed. In conclusion, this paper presents the current status of smart helmet technology, main issues, and prospects for future smart helmet with the objective of making the smart helmet concept a reality.
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Affiliation(s)
- Peter Lee
- KAIST Institute for Health Science and Technology, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Heepyung Kim
- KAIST Institute for Health Science and Technology, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - M Sami Zitouni
- College of Engineering and IT, University of Dubai, Dubai, United Arab Emirates
| | - Ahsan Khandoker
- Department of Biomedical Engineering, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Herbert F Jelinek
- Department of Biomedical Engineering, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Leontios Hadjileontiadis
- Department of Biomedical Engineering, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
- Department of Electrical and Computer Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Uichin Lee
- KAIST Institute for Health Science and Technology, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
- School of Computing, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
| | - Yong Jeong
- KAIST Institute for Health Science and Technology, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea
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7
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Kumar P, Gaurav A, Rajnish RK, Sharma S, Kumar V, Aggarwal S, Patel S. Applications of thermal imaging with infrared thermography in Orthopaedics. J Clin Orthop Trauma 2021; 24:101722. [PMID: 34926152 PMCID: PMC8646160 DOI: 10.1016/j.jcot.2021.101722] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Pathological conditions with ongoing inflammatory processes result in specific heat signatures at the affected body parts; infrared thermography (IRT) detects these changes and can be utilied in screening such conditions. The modern devices are advanced and their non contact, convenient and precise readings can aid in multiple medical sub fields. Orthopaedics as a broad entity has witnessed utilisation of this technology for different indications and the present scoping review was done to assess these established indications and further scope of its utility. METHOD ology: A Medline search was done on April 26, 2021 with specific keywords for studies of any design in English language discussing the usage of thermography in Orthopaedics. Animal studies, conference abstracts, systematic reviews, e-posters, case reports, book chapters, and studies describing the use of thermography in non-Orthopaedic patients were excluded. RESULTS Total number of hits were 1380. 43 studies including case series and case control studies were included in the review. The subfields or indications described were pain/arthritis, Charcot's foot/neuropathic ulcers, infections associated with diabetic feet and arthroplasties, reflex sympathetic dystrophy, carpal tunnel syndrome, sports medicine, paediatric orthopaedics, spine, ergonomics and compartment syndrome. CONCLUSION IRT has been described to be effective in orthopaedic conditions with specific heat signatures and this can assess the trend of the ongoing inflammatory process as well as response to a particular treatment. Additionally, it can specifically determine the exact loci of the pathology for targeted interventions.
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Stromer W, Pabinger I, Ay C, Crevenna R, Donnerer J, Feistritzer C, Hemberger S, Likar R, Sevelda F, Thom K, Wagner B, Streif W. Pain management in hemophilia: expert recommendations. Wien Klin Wochenschr 2021; 133:1042-1056. [PMID: 33661391 PMCID: PMC8500904 DOI: 10.1007/s00508-020-01798-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/11/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION As a typical consequence of bleeding into muscles and joints, patients with severe hemophilia suffer from acute and chronic pain. In spite of its high prevalence, pain in this patient group is not always sufficiently considered or treated in an effective manner. AIM The recommendations presented in this paper address possible improvements in pain management in hemophilia patients and particularities that have to be taken into account in this patient group. METHOD The manifold aspects of pain management in hemophilia patients were discussed within the framework of an expert meeting. Based on the available literature and the experts' clinical experience, the participants developed a set of recommendations presented in this paper. RESULTS Pain management in patients with hemophilia is often insufficient, a fact that not only influences the patients' quality of life but also implies the risk of difficult to manage chronic pain. Both the prevalent polypharmacy (due to comorbidities) as well as the underlying disease itself present special challenges to pain therapy in this patient group. The present review and recommendations are intended to support medical professionals in recognising the risks of pain chronicity, applying basic principles of multimodal pain therapy, including the options of psychological intervention and modalities of physical medicine in therapy concepts, and reaching a comprehensive understanding of the range of analgesic options available.
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Affiliation(s)
- Waltraud Stromer
- Department for Anaesthesia and General Intensive Care, Horn State Hospital, Spitalgasse 10, 3580, Horn, Austria
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Richard Crevenna
- University Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Josef Donnerer
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Clemens Feistritzer
- University Hospital for Internal Medicine V/Haematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sophie Hemberger
- University Department of Paediatric and Adolescent Medicine, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Rudolf Likar
- Department for Anaesthesia and Intensive Care, State Hospital Klagenfurt am Woerthersee, Klagenfurt, Austria
- Wolfsberg State Hospital, Wolfsberg, Austria
- Palliative Care, Sigmund Freud University Vienna, Klagenfurt, Austria
| | - Florian Sevelda
- University Department of Orthopaedics and Trauma Surgery, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Katharina Thom
- University Department of Paediatric and Adolescent Medicine, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Barbara Wagner
- University Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna/Vienna General Hospital, Vienna, Austria
| | - Werner Streif
- Department of Pediatrics, Medical University of Innsbruck, Innrain 52, 6020, Innsbruck, Austria.
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9
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Etzweiler D, Albisetti M, Meichtry A, Huber EO. The effect of age on the pressure pain threshold of asymptomatic ankles and knees in young individuals with haemophilia. Haemophilia 2021; 27:683-689. [PMID: 34015164 DOI: 10.1111/hae.14344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/24/2021] [Accepted: 05/03/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite adequate medical treatment, many young adults with haemophilia develop joint alterations-especially in ankles and knees. Undetected over years, subtle structural changes cause subclinical symptoms, before problems become obvious. To objectify these silent pressure pains, the pressure pain threshold (PPT) can be measured by algometry. AIM The aim was to investigate and compare the effect of age on PPTs in asymptomatic ankles and knees between boys and young adults with haemophilia and age-matched controls, in order to gain better knowledge about the alteration of the periarticular structures with increasing age. MATERIAL AND METHODS Nineteen persons with haemophilia (PwH; severe or moderate; 8-30 years) and 19 age-matched controls with 'healthy' ankles and knees were recruited. Asymptomatic joints with a Haemophilia Joint Health Score = 0 were included. The PPT was measured on four periarticular points per joint, and the data were analysed with a linear mixed model. RESULTS The PPT of the control group increased with age, whereas the PPT of the PwH decreased. The difference in age effect per year in kPa between PwH and controls was as follows: β [95%-CI]: -15.41 [-31.63; 0.79]. Although the result was not statistically significant (p = .08), a clear tendency was shown. CONCLUSION The results suggest that subclinical alterations in the periarticular structures of these joints may evolve unnoticed over time. However, further research is warranted to determine whether this observed trend is confirmed in a larger sample and at what age the PPT begins to decrease in PwH compared to controls.
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Affiliation(s)
- Denise Etzweiler
- Division of Haematology, University Children's Hospital Zurich, Zurich, Switzerland.,School of Health Professions, Institute of Physiotherapy, University of Applied Sciences, Winterthur, Switzerland
| | - Manuela Albisetti
- Division of Haematology, University Children's Hospital Zurich, Zurich, Switzerland
| | - André Meichtry
- School of Health Professions, Institute of Physiotherapy, University of Applied Sciences, Winterthur, Switzerland
| | - Erika O Huber
- School of Health Professions, Institute of Physiotherapy, University of Applied Sciences, Winterthur, Switzerland
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10
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Gooding R, Thachil J, Alamelu J, Motwani J, Chowdary P. Asymptomatic Joint Bleeding and Joint Health in Hemophilia: A Review of Variables, Methods, and Biomarkers. J Blood Med 2021; 12:209-220. [PMID: 33833602 PMCID: PMC8023018 DOI: 10.2147/jbm.s304597] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/19/2021] [Indexed: 12/14/2022] Open
Abstract
Joint health is a key contributor to quality of life in patients with hemophilia. However, variables that impact long-term joint outcomes have not been comprehensively defined. A systematic literature search identified publications relating to joint health in patients with hemophilia. Studies clearly show that early, sustained prophylaxis with factor replacements improves long-term joint outcomes. However, a subset of patients appear to develop arthropathy despite maintaining excellent bleeding outcomes, which suggests possible recurrent asymptomatic bleeding into the joints in these patients. Furthermore, limited data are available on how long-acting factor VIII and factor IX replacement therapies could impact long-term joint outcomes. Many variables were identified as potential indicators that a patient may develop hemophilic arthropathy, including genetic mutations, endogenous factor VIII and IX levels, bone health, and physical activity levels. Tools for the diagnosis and monitoring of hemophilic arthropathy are critical to detect early joint damage, so that management can be adjusted accordingly. Imaging techniques, particularly magnetic resonance imaging, can detect synovial changes, a strong predictor for the future development of hemophilic arthropathy. In addition, several biomarkers associated with cartilage and bone formation, vascularization, and angiogenesis could potentially identify the onset and progression of early joint damage. Since the development of hemophilic arthropathy is complex, a comprehensive therapeutic approach is necessary for the effective prevention of arthropathy in patients with hemophilia.
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Affiliation(s)
- Richard Gooding
- Leicester Haemophilia Centre, Haemostasis & Thrombosis Unit, Leicester Royal Infirmary, Leicester, UK
| | - Jecko Thachil
- Haematology Department, Manchester Royal Infirmary, Manchester, UK
| | - Jayanthi Alamelu
- Haemophilia Department, Evelina Children's Hospital - St Thomas' Hospital, London, UK
| | - Jayashree Motwani
- Haemophilia Comprehensive Care Centre, Birmingham Children's Hospital, Birmingham, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre, Royal Free Hospital, London, UK
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11
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Handwriting Analysis in Children and Adolescents with Hemophilia: A Pilot Study. J Clin Med 2020; 9:jcm9113663. [PMID: 33202574 PMCID: PMC7697872 DOI: 10.3390/jcm9113663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/06/2020] [Accepted: 11/12/2020] [Indexed: 12/26/2022] Open
Abstract
Background: Handwriting is a complex task that requires the integrity of different sensorimotor components to be performed successfully. Patients with hemophilia suffer from recurrent joint bleeds that may occur in the elbow, causing elbow dysfunction with handwriting performance impairment. In our study, we described instrumental dysgraphia that is related to functional disturbances. This pilot study aims to evaluate the handwriting performance in a group of patients with hemophilia. Methods: The study was performed at the Angelo Bianchi Bonomi Hemophilia and Thrombosis Center in Milan. Boys with severe and moderate hemophilia A and B regularly followed-up at that Center, with age between 6–19 years, were eligible. Patients were invited to the Center for one multidisciplinary evaluation of the upper limbs that included: Clinical examination, surface electromyography, and handwriting assessment. Results: All patients, but one, completed handwriting assessment. Overall, 14/19 (74%) had abnormal handwriting, which was overt instrumental dysgraphia in six (32%). There was no difference in Hemophilia Joint Health Score (HJHS) between dysgraphic and non-dysgraphic boys, while surface electromyography (sEMG) revealed a prevalence of flexor muscles of the upper limb in dysgraphic as compared with non-dysgraphic boys. Conclusions: The rather high prevalence of instrumental dysgraphia found in this pilot study deserves a further development of this preliminary experience by increasing the number of examined patients and comparing them with a control group, including quality of life and psychological assessment.
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12
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An Evaluation of Posture Recognition Based on Intelligent Rapid Entire Body Assessment System for Determining Musculoskeletal Disorders. SENSORS 2020; 20:s20164414. [PMID: 32784732 PMCID: PMC7472503 DOI: 10.3390/s20164414] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/30/2020] [Accepted: 08/06/2020] [Indexed: 12/11/2022]
Abstract
Determining the potential risks of musculoskeletal disorders through working postures in a workplace is expensive and time-consuming. A novel intelligent rapid entire body assessment (REBA) system based on convolutional pose machines (CPM), entitled the Quick Capture system, was applied to determine the risk levels. The aim of the study was to validate the feasibility and reliability of the CPM-based REBA system through a simulation experiment. The reliability was calculated from the differences of motion angles between the CPM-based REBA and a motion capture system. Results show the data collected by the Quick Capture system were consistent with those of the motion capture system; the average of root mean squared error (RMSE) was 4.77 and the average of Spearman’s rho (ρ) correlation coefficient in the different 12 postures was 0.915. For feasibility evaluation, the linear weighted Cohen’s kappa between the REBA score obtained by the Quick Capture system and those from the three experts were used. The result shows good agreement, with an average proportion agreement index (P0) of 0.952 and kappa of 0.738. The Quick Capture system does not only accurately analyze working posture, but also accurately determines risk level of musculoskeletal disorders. This study suggested that the Quick Capture system could be applied for a rapid and real-time on-site assessment.
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13
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Wagner B, Seuser A, Krüger S, Herzig ML, Hilberg T, Ay C, Hasenöhrl T, Crevenna R. Establishing an online physical exercise program for people with hemophilia. Wien Klin Wochenschr 2019; 131:558-566. [PMID: 31535221 PMCID: PMC6851214 DOI: 10.1007/s00508-019-01548-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 08/06/2019] [Accepted: 08/22/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hemophilia is a congenital bleeding disorder with an estimated frequency of 1:10,000 births. Repeated joint bleeding is a hallmark of the disorder and leads to painful hemophilic arthropathy. Regular exercise can help improve joint stability and function, reduce the risk of injury and bleeding and improve physical fitness and quality of life. This method paper describes an online training concept aiming to offer access to appropriate exercise instructions for people with hemophilia who are not able to attend regular training at a hemophilia center. METHODS The online exercise program is accessible through the homepage of the Department of Physical Medicine, Rehabilitation and Occupational Medicine of the Medical University Vienna as well as through scanning a QR code printed on information material using a smart phone or tablet. RESULTS The program contains exercises to improve mobility, coordination, muscular strength and flexibility. A brief introduction is given by a hematologist, a pediatrician and a physiatrist. An introductory video informs about contraindications and essential precautions, such as medical attendance and sufficient factor therapy to consider before starting the training. Another video gives advice on the exercise composition. The demonstrated exercises are explained by a physician and are available for adults and children. To individualize training recommendations and offer further diagnostic tools and physical treatment options as necessary, the Department of Physical Medicine, Rehabilitation and Occupational Medicine of the Medical University of Vienna will establish consultation hours for people with hemophilia. CONCLUSION As hemophilia is an orphan disease, patients are mainly treated in specialized centers. For patients who live far from these centers or have limited access to a training there for other reasons, the physical medicine consultation hour and the implementation of online exercise instructions offer individually adapted exercise information for a regular home-based training to benefit from increased physical fitness and joint stability.
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Affiliation(s)
- Barbara Wagner
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Axel Seuser
- Practice for Rehabilitation, Prevention and Orthopedics, Hans-Böckler-Straße 19, 53225, Bonn, Germany
| | - Steffen Krüger
- Department of Sports Medicine, University of Wuppertal, Moritzstraße 14, 42117, Wuppertal, Germany
| | - Marie Luca Herzig
- Department of Sports Medicine, University of Wuppertal, Moritzstraße 14, 42117, Wuppertal, Germany
| | - Thomas Hilberg
- Department of Sports Medicine, University of Wuppertal, Moritzstraße 14, 42117, Wuppertal, Germany
| | - Cihan Ay
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Timothy Hasenöhrl
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Richard Crevenna
- Department of Physical Medicine, Rehabilitation and Occupational Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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14
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Scheidt S, Rüwald J, Schildberg FA, Mahlein AK, Seuser A, Wirtz DC, Jacobs C. A Systematic Review on the Value of Infrared Thermography in the Early Detection of Periprosthetic Joint Infections. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:397-405. [PMID: 31525794 DOI: 10.1055/a-0969-8675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Variations in the temperature of body and skin are symptoms of many pathological changes. Although joint replacement surgery of hip and knee has been very successful in recent decades, periprosthetic infection is a growing problem and the number one reason for revision. While many studies have investigated changes in blood levels, investigation of temperature has not been performed on a regular basis. The objective of this work is to determine whether reference literature exists for the infrared thermographic examination in knee and hip arthroplasty and if reference values can be derived for the methodology or if there is a peri- and postoperative benefit. MATERIAL UND METHODS By means of a systematic online database search and based on the Cochrane, PICOT and PRISMA guidelines, this systematic review retrieved 254 studies. All publications with thermographic examination in arthroplasty of the hip and knee were imbedded. 249 studies were excluded due to the defined inclusion and exclusion criteria and five studies with 251 patients have finally been included in the evaluation process. This was followed by an analysis and discussion of the methodology. RESULTS AND CONCLUSION Infrared thermography is a useful tool in the perioperative care of patients after arthroplasty of the knee and hip joint. The technology is portable, easy to use and non-invasive. Based only on these few publications, values can be derived, which provide a guidance for the thermographic aftercare in arthroplasty surgery.
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Affiliation(s)
- Sebastian Scheidt
- Department of Orthopaedics and Trauma Surgery University Hospital Bonn, Germany
| | - Julian Rüwald
- Department of Orthopaedics and Trauma Surgery University Hospital Bonn, Germany
| | | | | | - Axel Seuser
- Private Practice for Prevention, Rehabilitation and Orthopaedics, Bonn, Germany
| | | | - Cornelius Jacobs
- Department of Orthopaedics and Trauma Surgery University Hospital Bonn, Germany
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15
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Factor VIII: Long-established role in haemophilia A and emerging evidence beyond haemostasis. Blood Rev 2019; 35:43-50. [DOI: 10.1016/j.blre.2019.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/01/2019] [Accepted: 03/01/2019] [Indexed: 12/20/2022]
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16
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Cabizosu A, Carboni N, Figus A, Vegara-Meseguer JM, Casu G, Hernández Jiménez P, Martinez-Almagro Andreo A. Is infrared thermography (IRT) a possible tool for the evaluation and follow up of Emery-Dreifuss muscular dystrophy? A preliminary study. Med Hypotheses 2019; 127:91-96. [PMID: 31088657 DOI: 10.1016/j.mehy.2019.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/22/2019] [Accepted: 04/12/2019] [Indexed: 11/28/2022]
Abstract
HYPOTHESIS The hypothesis of this work is that infrared thermography could become a valid tool for the diagnosis and follow-up of the Emery-Dreifuss disease due to putative temperature changes produced by a constant degenerative evolution of this muscular dystrophy. TESTING THE HYPOTHESIS To justify this hypothesis we proposed a pilot study with 2 brothers affected of Emery-Dreifuss who present a very different age, with the principal objective to evidence a possible evolution of this pathology. Acquisition and comparison of images of computerized axial tomography (CT) and thermography (IRT) of the distal limbs in 2 affected brothers. DATA AND DISCUSSION Important image correlations in the region of the thighs and the posterior region of the legs have been highlighted. The comparison between the CT and the thermography showed how the first results are encouraged and promising and open a possible new line of research on the evaluation and follow-up of this disease. Despite this, a larger number of studies are needed to validate the thermography as a diagnostic technique and follow-up of this pathology.
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Affiliation(s)
- A Cabizosu
- Universidad Católica de Murcia (UCAM), Spain.
| | - N Carboni
- Azienda Sanitaria Locale Nuoro, Hospital San Francesco, Italy
| | - A Figus
- Azienda Sanitaria Locale Nuoro, Hospital San Francesco, Italy
| | | | - G Casu
- Azienda Sanitaria Locale Nuoro, Hospital San Francesco, Italy
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17
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Puetz J. Nano-evidence for joint microbleeds in hemophilia patients. J Thromb Haemost 2018; 16:1914-1917. [PMID: 30007042 DOI: 10.1111/jth.14242] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/06/2018] [Indexed: 11/26/2022]
Abstract
The concept of joint microbleeding in hemophilia patients was first proposed over 10 years ago. This was based on unexpected abnormalities found in medical imaging studies of asymptomatic joints. Since then, there have been no published studies confirming the presence of joint microbleeds. This critique will review the evidence for and against joint microbleeding in hemophilia patients and the potential implications.
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Affiliation(s)
- J Puetz
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, MO, USA
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18
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Online Identification of Shearer Cutting State Using Infrared Thermal Images of Cutting Unit. APPLIED SCIENCES-BASEL 2018. [DOI: 10.3390/app8101772] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In order to achieve accurate identification of a shearer cutting state, infrared thermal images were creatively adopted in this paper. As the position of a shearer cutting unit is constantly changing, and the temperature in the vicinity is obviously distinct, mathematical morphology theory was used to detect the cutting unit in an infrared thermal image. Furthermore, a target tracking method is put forward to achieve cutting unit tracking based on the combination of morphology and a spatio-temporal context (STC) algorithm. Then, the temperature field features of this tracking area were extracted, and an intelligent classifier based on a support vector machine (SVM) was constructed to identify the cutting state of the shearer. Some experiments are presented, and the results indicate the feasibility and superiority of the proposed method.
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19
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Seuser A, Djambas Khayat C, Negrier C, Sabbour A, Heijnen L. Evaluation of early musculoskeletal disease in patients with haemophilia: results from an expert consensus. Blood Coagul Fibrinolysis 2018; 29:509-520. [PMID: 30020119 PMCID: PMC6125749 DOI: 10.1097/mbc.0000000000000767] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/26/2018] [Accepted: 07/05/2018] [Indexed: 11/25/2022]
Abstract
: Early joint damage in patients with haemarthrosis often escapes diagnosis because of insufficient investigation of biomechanical changes. Arthropathy in haemophilia requires complex assessment with several tools. Considering the increased emphasis on an integrated approach to musculoskeletal (MSK) outcomes, re-evaluation of MSK assessment to address individual patient needs is warranted. To advise on the optimal use of current assessment tools and strategies for tailored MSK evaluation in patients with haemophilia. A panel of experts in haemophilic arthropathy evaluated internationally recognized assessment tools through published literature and personal expertise. Each tool was considered, scored and ranked for their utility in the clinical assessment of MSK damage. Subsequently, a patient evaluation table detailing advice on type and frequency of assessments for different patient populations was constructed. To obtain a complete MSK assessment, multiple tools must be used to ensure each criterion is evaluated. For patients with haemophilia, clinical examination of the joint, disease-specific structure/function scores, and activity/participation scores including quality of life are important, and should be performed on a regular basis according to age and clinical condition. Joint imaging is recommended in the prevention, diagnosis and follow-up of haemophilic arthropathy and should be used in conjunction with joint structure and function scores. An integrated approach to MSK assessment using combinations of tools will allow earlier management of dysfunction and may improve long-term outcomes. This approach could be used in long-term follow-up of all patients independent of age and disease stage, especially in children to prevent arthropathy.
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Affiliation(s)
- Axel Seuser
- Private Practice for Prevention, Rehabilitation and Orthopaedics, Bonn, Germany
| | | | - Claude Negrier
- Centre Régional de Traitement de l’Hémophilie, Louis Pradel, University Claude Bernard, Lyon, France
| | - Adly Sabbour
- Physiotherapy Department, Cairo University, Egypt
| | - Lily Heijnen
- Van Creveldkliniek, UMC, Utrecht, the Netherlands
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20
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Rodriguez-Merchan EC. Hemophilic arthropathy: current treatment challenges and future prospects. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1508341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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