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Ahmed SK, Petersen IA, Grams MP, Finley RR, Haddock MG, Owen D. Spatially Fractionated Radiation Therapy in Sarcomas: A Large Single-Institution Experience. Adv Radiat Oncol 2024; 9:101401. [PMID: 38495033 PMCID: PMC10943518 DOI: 10.1016/j.adro.2023.101401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/16/2023] [Indexed: 03/19/2024] Open
Abstract
Purpose Spatially fractionated radiation therapy (SFRT) is a recognized technique for enhancing tumor response in radioresistant and bulky tumors. We analyzed clinical and treatment outcomes in patients with bone and soft tissue sarcomas treated with modern SFRT techniques. Methods and Materials Patients with metastatic or unresectable sarcoma treated with brass collimator, volumetric modulated arc therapy lattice, or proton SFRT from December 2019 to June 2022 were retrospectively reviewed. Consolidative external beam radiation therapy (EBRT) was delivered at the physician's discretion. Patient and treatment characteristics, treatment response (symptom improvement, local control, and imaging response), and toxicity data were collected. Results The cohort consisted of 53 patients treated with 61 SFRT treatments. Median age at treatment was 60.0 years. The primary location was soft tissue in 46 courses (75%) and bone in 15 (25%). Fifty-three courses (87%) were treated for symptom relief. The most used SFRT technique was volumetric modulated arc therapy lattice (n = 52, 85%) to a dose of 20 Gy (n = 48, 79%; range, 16-20 Gy). EBRT was delivered post-SFRT in 55 (90%) treatment courses with a median time interval from SFRT to EBRT of 5 days (range, 0-14 days). Median physical EBRT dose and fractionation was 40 Gy (range, 9-73.5 Gy) and 10 fractions (range, 3-33 fractions). Median follow up was 7.4 months (range, 0.2-30 months). One-year overall survival and local control rates were 53% and 82%. Symptom relief was documented with 32 treatment courses (60%). Stable or partial response was observed with 47 treatment courses (90%). Four grade 3 to 4 acute and subacute toxicities were attributable to SFRT (8%). Conclusions The current series is the largest to date documenting outcomes for SFRT in sarcomas. Our results suggest combined SFRT with EBRT is associated with a favorable toxicity profile and high rates of symptomatic and radiographic responses for metastatic or unresectable sarcomas.
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Affiliation(s)
- Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Ivy A. Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Michael P. Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Randi R. Finley
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Grams MP, Deufel CL, Kavanaugh JA, Corbin KS, Ahmed SK, Haddock MG, Lester SC, Ma DJ, Petersen IA, Finley RR, Lang KG, Spreiter SS, Park SS, Owen D. Clinical aspects of spatially fractionated radiation therapy treatments. Phys Med 2023; 111:102616. [PMID: 37311338 DOI: 10.1016/j.ejmp.2023.102616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/06/2023] [Accepted: 05/30/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE To provide clinical guidance for centers wishing to implement photon spatially fractionated radiation therapy (SFRT) treatments using either a brass grid or volumetric modulated arc therapy (VMAT) lattice approach. METHODS We describe in detail processes which have been developed over the course of a 3-year period during which our institution treated over 240 SFRT cases. The importance of patient selection, along with aspects of simulation, treatment planning, quality assurance, and treatment delivery are discussed. Illustrative examples involving clinical cases are shown, and we discuss safety implications relevant to the heterogeneous dose distributions. RESULTS SFRT can be an effective modality for tumors which are otherwise challenging to manage with conventional radiation therapy techniques or for patients who have limited treatment options. However, SFRT has several aspects which differ drastically from conventional radiation therapy treatments. Therefore, the successful implementation of an SFRT treatment program requires the multidisciplinary expertise and collaboration of physicians, physicists, dosimetrists, and radiation therapists. CONCLUSIONS We have described methods for patient selection, simulation, treatment planning, quality assurance and delivery of clinical SFRT treatments which were built upon our experience treating a large patient population with both a brass grid and VMAT lattice approach. Preclinical research and patient trials aimed at understanding the mechanism of action are needed to elucidate which patients may benefit most from SFRT, and ultimately expand its use.
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Affiliation(s)
- Michael P Grams
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Christopher L Deufel
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - James A Kavanaugh
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Kimberly S Corbin
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Randi R Finley
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Karen G Lang
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Sheri S Spreiter
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Grams MP, Owen D, Park SS, Petersen IA, Haddock MG, Jeans EB, Finley RR, Ma DJ. VMAT Grid Therapy: A Widely Applicable Planning Approach. Pract Radiat Oncol 2020; 11:e339-e347. [PMID: 33130318 DOI: 10.1016/j.prro.2020.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/26/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To describe a novel and practical volumetric modulated arc therapy (VMAT) planning approach for grid therapy. METHODS AND MATERIALS Dose is prescribed to 1.5-cm diameter spherical contours placed throughout the gross tumor volume (GTV). Placement of spheres is variable, but they must maintain at least a 3-cm (center to center) separation, and the edge of any sphere must be at least 1 cm from any organ at risk (OAR). Three concentric ring structures are used during optimization to confine the highest doses to the center of the spheres and maximize dose sparing between them. The end result is alternating regions of high and low dose throughout the GTV and minimal dose to OARs. High-intensity flattening filter-free (FFF) modes are used to efficiently deliver the plans, and entire treatments typically take only 15 to 20 minutes. RESULTS The approach is illustrated with 2 examples treated at our institution. Patient #1 had a 1703-cm3 mediastinal mass and was prescribed 20 Gray (Gy) to 24 spherical regions within the GTV. Patient #2 had a 3680-cm3 abdominal tumor and was prescribed 18 Gy to 32 spherical regions within the GTV. Both patients received additional consolidative radiation approximately 1 week after the initial VMAT grid treatment. Each patient experienced marked reduction in tumor size and symptomatic relief without treatment-related complications. CONCLUSIONS We have described in detail a planning approach for VMAT grid therapy treatments that can typically be delivered in a clinically practical time span. The VMAT approach is especially useful for tumors that are surrounded by sensitive critical structures. As many centers offer VMAT treatments, the approach is widely accessible and can be readily implemented once appropriate patient selection and delivery processes are established.
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Affiliation(s)
- Michael P Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Randi R Finley
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Wilhite TJ, Youland RS, Tian S, Finley RR, Sarkaria JN, Corbin KS. Pathogenic Germ Line Variants in a Patient With Severe Toxicity From Breast Radiotherapy. Clin Breast Cancer 2019; 19:e400-e405. [PMID: 31031124 DOI: 10.1016/j.clbc.2019.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/15/2019] [Accepted: 03/12/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Tyler J Wilhite
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Ryan S Youland
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Shulan Tian
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Randi R Finley
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Jann N Sarkaria
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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McGrath LA, Martenson JA, Finley RR. Recurrent Radiation Recall Mucosal Toxicity of the Upper Aerodigestive Tract: A Case Report. Adv Radiat Oncol 2019; 4:229-232. [PMID: 31011666 PMCID: PMC6460096 DOI: 10.1016/j.adro.2018.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 10/03/2018] [Accepted: 11/07/2018] [Indexed: 11/28/2022] Open
Affiliation(s)
- Laura A McGrath
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Randi R Finley
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Saiki H, Petersen IA, Scott CG, Bailey KR, Dunlay SM, Finley RR, Ruddy KJ, Yan E, Redfield MM. Risk of Heart Failure With Preserved Ejection Fraction in Older Women After Contemporary Radiotherapy for Breast Cancer. Circulation 2017; 135:1388-1396. [PMID: 28132957 DOI: 10.1161/circulationaha.116.025434] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/13/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cardiomyocytes are resistant to radiation. However, cardiac radiation exposure causes coronary microvascular endothelial inflammation, a perturbation implicated in the pathogenesis of heart failure (HF) and particularly HF with preserved ejection fraction (HFpEF). Radiotherapy for breast cancer results in variable cardiac radiation exposure and may increase the risk of HF. METHODS We conducted a population-based case-control study of incident HF in 170 female residents of Olmsted County, Minnesota (59 cases and 111 controls), who underwent contemporary (1998-2013) radiotherapy for breast cancer with computed tomography-assisted radiotherapy planning. Controls were matched to cases for age, tumor side, chemotherapy use, diabetes mellitus, and hypertension. Mean cardiac radiation dose (MCRD) in each patient was calculated from the patient's computed tomography images and radiotherapy plan. RESULTS Mean age at radiotherapy was 69±9 years. Of HF cases, 38 (64%) had EF≥50% (HFpEF), 18 (31%) had EF<50% (HF with reduced EF), and 3 (5%) did not have EF measured. The EF was ≥40% in 50 of the 56 HF cases (89%) with an EF measurement. The mean interval from radiotherapy to HF was 5.8±3.4 years. The odds of HF was higher in patients with a history of ischemic heart disease or atrial fibrillation. The MCRD was 2.5 Gy (range, 0.2-13.1 Gy) and higher in cases (3.3±2.7 Gy) than controls (2.1±2.0 Gy; P=0.004). The odds ratio (95% confidence interval) for HF per log MCRD was 9.1 (3.4-24.4) for any HF, 16.9 (3.9-73.7) for HFpEF, and 3.17 (0.8-13.0) for HF with reduced EF. The increased odds of any HF or HFpEF with increasing MCRD remained significant after adjustment for HF risk factors and in sensitivity analyses matching by cancer stage rather than tumor side. Only 18.6% of patients experienced new or recurrent ischemic events between radiotherapy and the onset of HF. CONCLUSIONS The relative risk of HFpEF increases with increasing cardiac radiation exposure during contemporary conformal breast cancer radiotherapy. These data emphasize the importance of radiotherapy techniques that limit MCRD during breast cancer treatment. Moreover, these data provide further support for the importance of coronary microvascular compromise in the pathophysiology of HFpEF.
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Affiliation(s)
- Hirofumi Saiki
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Ivy A Petersen
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Christopher G Scott
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Kent R Bailey
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Shannon M Dunlay
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Randi R Finley
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Kathryn J Ruddy
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Elizabeth Yan
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN
| | - Margaret M Redfield
- From Department of Cardiovascular Disease (H.S., S.M.D., M.M.R.), Department of Radiation Oncology (I.A.P., R.R.F., E.Y.), Department of Health Science Research (C.G.S., K.R.B., S.M.D.), and Division of Medical Oncology (K.J.R.), Mayo Clinic and Foundation, Rochester, MN.
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Finley RR, Leeds AL. Improving drug therapy in the elderly. West J Med 1993; 159:511-2. [PMID: 7903833 PMCID: PMC1022308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Sharpe MD, Mustard RA, Finley RR, Rutledge FS, Sibbald WJ. Failure of therapy with 2,3-dihydroxybenzoic acid to modify the course of sepsis-induced lung injury. J Appl Physiol (1985) 1990; 69:1893-902. [PMID: 2272983 DOI: 10.1152/jappl.1990.69.5.1893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Oxidant-induced injury of the pulmonary microvasculature reportedly contributes to an increase in microvascular permeability and pulmonary hypertension, both of which are principal features of acute lung injury (ALI). We tested the hypothesis that antioxidant therapy with 2,3-dihydroxybenzoic acid (DHB), initiated in awake sheep after the development of sepsis-induced ALI, would ameliorate the progression of these lesions. DHB has many actions that suggested to us the potential for demonstrating benefit in ALI complicating sepsis; it is a nontoxic hydroxyl-radical scavenger that also inhibits the cyclooxygenase pathway and acts as a weak iron chelator. In preliminary experiments, we demonstrated that pretreatment with DHB prevented an increase in mean pulmonary arterial pressure, plasma thromboxane A2, measured as its metabolite thromboxane B2, and lymph total protein clearance that otherwise followed an infusion of zymosan-activated plasma (ZAP) in sheep. In subsequent experiments, 12 additional sheep were rendered septic by cecal ligation and perforation. Twenty-four to 36 h after cecal ligation and perforation, an increase in lung microvascular permeability was confirmed, because pulmonary lymph flow had increased by 82% while the mean lymph-to-plasma total protein ratio was unchanged from baseline. At this point, six sheep were then treated with parenteral DHB and six with DHB vehicle for the subsequent 24 h. In contrast to the demonstrated benefit of DHB pretreatment in preventing ALI secondary to an infusion of ZAP, the progressive increase in lymph total protein clearance that complicated septic lung injury in the DHB vehicle group throughout this 24-h study period was not ameliorated in the DHB treatment group. However, DHB did prevent a modest increase in mean pulmonary arterial pressures that was demonstrated in the DHB vehicle group throughout this 24-h treatment period. Although pretreatment prevented ALI after a ZAP infusion, we conclude that DHB only incompletely modified disease progression when administered after the onset of sepsis-induced ALI because it ameliorated the pulmonary hypertensive response without concurrently modifying an increase in lung microvascular fluid flux.
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Affiliation(s)
- M D Sharpe
- Richard Ivey Critical Care Trauma Centre, Victoria Hospital, London, Ontario, Canada
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Abstract
The effect on pulmonary fluid balance of adrenergic receptor agonist agents commonly employed in clinical sepsis has not been well characterized. Therefore, we tested the hypothesis that dobutamine would increase pulmonary microvasular fluid flux in experimental sepsis-induced lung injury. To define the effects of this synthetic catecholamine on pulmonary lymph flow (QL), we infused dobutamine in sheep at two doses in sequence (5 micrograms/kg/min and 10 micrograms/kg/min) before and after the induction of intraperitoneal sepsis which resulted in the development of lung microvascular injury. In the nonseptic state, cardiac output increased at both 5 micrograms/kg/min and 10 micrograms/kg/min (22 and 36 percent, respectively), while QL was unchanged from baseline (for 5 micrograms, delta QL = +0.44 +/- 1.35 ml/15 min; not significant) (for 10 micrograms, delta QL = -0.20 +/- 1.0 ml/15 min; not significant). Values for the ratio of lymph/plasma total protein levels [( L/P]TP) fell modestly in the nonseptic study at both doses (p less than 0.05). With established sepsis syndrome, QL increased from the nonseptic baseline study (2.99 +/- 1.8 to 7.01 +/- 3.95 ml/15 min; p less than 0.05), without change in [L/P]TP ratios or the calculated microvascular hydrostatic pressure. (Pmv) During sepsis, dobutamine infusion was again associated with an increase in cardiac output at both the 5 micrograms/kg/min (+29 percent) and 10 micrograms/kg/min (+33 percent) doses, while QL increased modestly only with the lower dose of dobutamine infused (5 micrograms/kg/min, delta QL = 1.80 +/- 2.2 ml/15 min; p less than 0.05). In this model of sepsis-induced lung injury, dobutamine increased systemic flow without substantially augmenting QL.
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Affiliation(s)
- A G Gnidec
- Richard Ivey Critical Care Trauma Centre, Victoria Hospital, London, Ontario, Canada
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