1
|
Duval D, Evans B, Sanders A, Hill J, Simbo A, Kavoi T, Lyell I, Simmons Z, Qureshi M, Pearce-Smith N, Arevalo CR, Beck CR, Bindra R, Oliver I. Non-pharmaceutical interventions to reduce COVID-19 transmission in the UK: a rapid mapping review and interactive evidence gap map. J Public Health (Oxf) 2024:fdae025. [PMID: 38426578 DOI: 10.1093/pubmed/fdae025] [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] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Non-pharmaceutical interventions (NPIs) were crucial in the response to the COVID-19 pandemic, although uncertainties about their effectiveness remain. This work aimed to better understand the evidence generated during the pandemic on the effectiveness of NPIs implemented in the UK. METHODS We conducted a rapid mapping review (search date: 1 March 2023) to identify primary studies reporting on the effectiveness of NPIs to reduce COVID-19 transmission. Included studies were displayed in an interactive evidence gap map. RESULTS After removal of duplicates, 11 752 records were screened. Of these, 151 were included, including 100 modelling studies but only 2 randomized controlled trials and 10 longitudinal observational studies.Most studies reported on NPIs to identify and isolate those who are or may become infectious, and on NPIs to reduce the number of contacts. There was an evidence gap for hand and respiratory hygiene, ventilation and cleaning. CONCLUSIONS Our findings show that despite the large number of studies published, there is still a lack of robust evaluations of the NPIs implemented in the UK. There is a need to build evaluation into the design and implementation of public health interventions and policies from the start of any future pandemic or other public health emergency.
Collapse
Affiliation(s)
- D Duval
- Research, Evidence and Knowledge Division, UK Health Security Agency (UKHSA), London E14 5EA, UK
| | - B Evans
- Research, Evidence and Knowledge Division, UK Health Security Agency (UKHSA), London E14 5EA, UK
| | - A Sanders
- Research, Evidence and Knowledge Division, UK Health Security Agency (UKHSA), London E14 5EA, UK
| | - J Hill
- Clinical and Public Health Response Division, UKHSA, London E14 5EA, UK
| | - A Simbo
- Evaluation and Epidemiological Science Division, UKHSA, Colindale NW9 5EQ, UK
| | - T Kavoi
- Cheshire and Merseyside Health Protection Team, UKHSA, Liverpool L3 1DS, UK
| | - I Lyell
- Greater Manchester Health Protection Team, UKHSA, Manchester M1 3BN, UK
| | - Z Simmons
- Research, Evidence and Knowledge Division, UK Health Security Agency (UKHSA), London E14 5EA, UK
| | - M Qureshi
- Clinical and Public Health Response Division, UKHSA, London E14 5EA, UK
| | - N Pearce-Smith
- Research, Evidence and Knowledge Division, UK Health Security Agency (UKHSA), London E14 5EA, UK
| | - C R Arevalo
- Research, Evidence and Knowledge Division, UK Health Security Agency (UKHSA), London E14 5EA, UK
| | - C R Beck
- Evaluation and Epidemiological Science Division, UKHSA, Salisbury SP4 0JG, UK
| | - R Bindra
- Clinical and Public Health Response Division, UKHSA, London E14 5EA, UK
| | - I Oliver
- Director General Science and Research and Chief Scientific Officer, UKHSA, London E14 5EA, UK
| |
Collapse
|
2
|
Castilho RM, Castilho MS, Simmons Z, Squarize CH. Empowering the youth to choose non-traditional careers in research and academia. J Oral Pathol Med 2023; 52:339-341. [PMID: 36694271 DOI: 10.1111/jop.13407] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/19/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUD The United States is facing a dramatic shortage of clinician-scientists within the domains of medicine and dentistry. POINT OF VIEW In this perspective article, we stressed the problem involving the continuous shortage of specialized professionals capable of addressing complex basic sciences questions, while maintaining clinical relevance. Here we present a different perspective regarding the early engagement of young students to clinical sciences by teaming up with high schools across the United States, and to energize the debate on our current shortage of clinician-scientists.
Collapse
Affiliation(s)
- Rogerio M Castilho
- Department of Periodontics and Oral Medicine, Laboratory of Epithelial Biology, University of Michigan School of Dentistry, Ann Arbor, Michigan, USA.,University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, USA
| | | | - Zoë Simmons
- Community High School, Ann Arbor, Michigan, USA
| | - Cristiane H Squarize
- Department of Periodontics and Oral Medicine, Laboratory of Epithelial Biology, University of Michigan School of Dentistry, Ann Arbor, Michigan, USA.,University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, USA
| |
Collapse
|
3
|
Nielson S, Simmons Z, Kay D. 0403 Sleep Valuation: A Novel Construct and Questionnaire. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.400] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Sleep valuation, the relative worth of one’s own sleep, is an under-explored construct that could have implications on sleep health. This study sought to validate the Sleep Valuation Questionnaire (SVQ) and to explore demographic differences in sleep valuation.
Methods
Participants (N = 946) recruited through TurkPrime were stratified across age (18-99), race (50% White, 17% Black, and 8.33% for each American Indian, Asian, Pacific Islander, and other), Hispanic ethnicity (20%), gender (50/50 female/male), employment status (50% employed full time and 8.33% for each part time, homemaker, retired, student, temp worker. unemployed, and disabled), Participants completed a demographic survey, followed by the original 43 item SVQ completed twice. Iterated principal factoring with a Promax solution was used to identify the factor structure of the SVQ. Cronbach’s alpha and correlation analyses were also used to help identify items with poor reliability. Total sleep valuation, the sum of valid items on the SVQ, was used as the dependent variable in a multiple regression analysis. Age, gender, race, work status, socioeconomic status, educational level, marital status, and general health and mental health estimates served as independent variables.
Results
After removing items with weak factor loadings (<0.6), poor reliability, and weak face validity, the number of items were reduced to 10, which loaded on to 2 factors: Sleep Desire and Sleep Need. Those who cohabitate had lower SVQ scores than married individuals (p=0.04), full-time workers had higher SVQ scores than non-full-time workers (p=0.001), higher age was associated with lower SVQ scores (p<0.001), and higher general mental health was associated with lower SVQ scores (p<0.001).
Conclusion
This is the first study to explore how demographic variables relate to sleep valuation. The SVQ may help identify factors that contribute to sleep valuation and sleep valuation relates to sleep behavior, sleep health, and sleep treatment utilization.
Support
None
Collapse
Affiliation(s)
| | | | - D Kay
- Brigham Young University, Provo, UT
| |
Collapse
|
4
|
Flaherty C, Kraft J, Brothers A, Harrison M, Legro R, Manni A, Yang C, Simmons Z. The relationship between oestrogen and executive functioning in ALS females with emerging Frontotemporal Lobar Degeneration (FTLD) supports a neuroendocrine model of FTLD attenuation. Amyotroph Lateral Scler Frontotemporal Degener 2016; 18:74-85. [DOI: 10.1080/21678421.2016.1249487] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- C. Flaherty
- Department of Neurology, Penn State College of Medicine, Hershey, PA, USA,
| | - J. Kraft
- Department of Psychology, Penn State University, Middletown, PA, USA,
| | - A. Brothers
- Department of Human Development and Family Studies, Colorado State University, Fort Collins, CO, USA,
| | - M. Harrison
- Department of Psychology, Penn State University, Middletown, PA, USA,
| | - R.S. Legro
- Department of OB/GYN, Penn State College of Medicine, Hershey, PA, USA,
| | - A. Manni
- Division of Endocrinology, Diabetes and Metabolism, Penn State College of Medicine, Hershey, PA, USA, and
| | - C. Yang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Z. Simmons
- Department of Neurology, Penn State College of Medicine, Hershey, PA, USA,
| | | |
Collapse
|
5
|
Sudhin PP, Nafin KS, Simmons Z, Sudhikumar AV. On the type species of the genus Aetius O. Pickard-Cambridge, 1896: The first description of male with notes on cymbial notch and mating plug (Araneae: Corinnidae: Castianeirinae). Zootaxa 2016; 4154:489-500. [PMID: 27615855 DOI: 10.11646/zootaxa.4154.4.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Indexed: 11/04/2022]
Abstract
The rare ant mimicking sac spider genus Aetius was erected by O. Pickard-Cambridge in 1896 based on an unspecified number of female specimen(s) collected from Sri Lanka. The type species of the genus, A. decollatus O. Pickard-Cambridge, 1896, has been redescribed twice based on the holotype (Majumder & Tikader 1991; Deeleman-Reinhold 2001). Reimoser (1934) recorded the genus for the first time from India, who collected a male specimen from Mudumalai Tiger Reserve in Tamil Nadu State of southern India. This specimen was identified as A. decollatus, but it was never formally described and was later recognised to be a penultimate male (Dankittipakul & Singtripop 2013). Deeleman-Reinhold (2001) described the second representative of the genus, A. nocturnus, based on a single female specimen from Borneo, 105 years after the establishment of the genus. Dankittipakul & Singtripop (2013) described the male of A. nocturnus, thereby revealing the male genitalia of the genus, but the type species was still known only from the female sex.
Collapse
Affiliation(s)
- Puthoor Pattammal Sudhin
- Centre for Animal Taxonomy and Ecology, Department of Zoology, Christ College, Irinjalakuda, Kerala, 680 125, India; unknown
| | | | - Zoë Simmons
- Oxford University Museum of Natural History, Parks Road, Oxford, OX1 3PW, United Kingdom; unknown
| | - Ambalaparambil Vasu Sudhikumar
- Centre for Animal Taxonomy and Ecology, Department of Zoology, Christ College, Irinjalakuda, Kerala, 680 125, India; unknown
| |
Collapse
|
6
|
Geronimo A, Simmons Z, Schiff SJ. Performance predictors of brain–computer interfaces in patients with amyotrophic lateral sclerosis. J Neural Eng 2016; 13:026002. [DOI: 10.1088/1741-2560/13/2/026002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
7
|
Levi BH, Brothers A, Whitehead M, Simmons Z, Farace E, Schubart J, Lehmann E, Green MJ. Advance care planning decision aid improves clinician understanding of wishes of patients with ALS. BMJ Support Palliat Care 2012. [DOI: 10.1136/bmjspcare-2012-000250.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
8
|
Shefner J, Barohn R, Boylan K, Bradshaw D, Brooks B, Heiman-Patterson T, Katz J, Maragakis N, Mitsumoto H, Pestronk A, Simmons Z, Wolff A, Lee J, Masonek J, Jones D, Meng L, Cedarbaum J. A Study To Evaluate Safety, and Tolerability of Repeated Doses of CK-2017357 (CK-357) in Patients with Amyotrophic Lateral Sclerosis (S25.005). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.s25.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
9
|
Bede P, Oliver D, Stodart J, van den Berg L, Simmons Z, Brannagain DO, Borasio GD, Hardiman O. Palliative care in amyotrophic lateral sclerosis: a review of current international guidelines and initiatives. BMJ Support Palliat Care 2011; 1:343-8. [DOI: 10.1136/bmjspcare.2010.232637.rep] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
10
|
Mitchell RM, Freeman WM, Randazzo WT, Stephens HE, Beard JL, Simmons Z, Connor JR. A CSF biomarker panel for identification of patients with amyotrophic lateral sclerosis. Neurology 2008; 72:14-9. [DOI: 10.1212/01.wnl.0000333251.36681.a5] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
11
|
Simmons Z, Felgoise SH, Bremer BA, Walsh SM, Hufford DJ, Bromberg MB, David W, Forshew DA, Heiman-Patterson TD, Lai EC, McCluskey L. The ALSSQOL: balancing physical and nonphysical factors in assessing quality of life in ALS. Neurology 2006; 67:1659-64. [PMID: 17101900 DOI: 10.1212/01.wnl.0000242887.79115.19] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [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: 11/15/2022] Open
Abstract
BACKGROUND There is no generally accepted instrument for measuring quality of life (QOL) in patients with ALS. Current instruments are either too heavily weighted toward strength and physical function or useful for the evaluation of individuals but of less utility in assessing large samples. OBJECTIVE To develop and evaluate the psychometric properties of an ALS-specific QOL instrument (the ALSSQOL) that would reflect overall QOL as assessed by the patient and would be valid and reliable across large samples. METHODS The ALSSQOL is based on the McGill Quality of Life Questionnaire (MQOL), modified by changes in format and by adding questions on religiousness and spirituality, items derived from interviews with ALS patients, and items identified from open-ended questions administered during the MQOL. The psychometric properties of the ALSSQOL were assessed by a prospective multicenter study in which participants completed the ALSSQOL, other instruments measuring overall QOL, and instruments assessing religiousness, spirituality, and psychological distress. RESULTS A 59-item ALSSQOL was developed; 342 patients evaluated its psychometric properties. Completion time averaged 15 minutes. Forty-six items loaded on six factors. The ALSSQOL demonstrated concurrent, convergent, and discriminant validity for the overall instrument and convergent validity for its subscales. Analysis of individual items permitted insight into variables of clinical importance. CONCLUSIONS This new ALS-specific quality of life instrument is a practical tool for the assessment of overall quality of life in individuals with ALS and appears to be valid and useful across large samples. Validation studies of a shortened version are now under way.
Collapse
Affiliation(s)
- Z Simmons
- Department of Neurology, Penn State College of Medicine, Hershey, PA 17033, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Chung JS, Schlunt LB, Simmons Z, Shah SK, Maeda G, Baldwin DD. 496 UPPER POLE RENAL ACCESS: IS A NOVEL SINGLE-STEP SHEATH EASIER TO INSERT THAN THE CONVENTIONAL TWO-STEP DEVICE? J Investig Med 2005. [DOI: 10.2310/6650.2005.00005.495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
13
|
Abstract
Although the reproducibility of motor unit number estimation (MUNE) for groups of subjects has been studied, there is little such data for individuals. Prediction intervals represent a tool to study individual MUNE reproducibility and represent the range of values expected for a future MUNE if the true number of motor units remains unchanged. MUNE was performed using the statistical method on 48 normal individuals. The prediction interval was found to be a function of the intrasubject coefficient of variation. Using a commercial manufacturer's recommended technique and software, prediction intervals were found to be so broad as to be of uncertain value. We found that by averaging two MUNE observations for each determination, and using the method of weighted averages for calculating the size of an average single motor unit potential, the intrasubject coefficient of variation was reduced from 16.48% to 8.77%, and the 90% prediction interval became sufficiently narrow to be clinically useful. False-negative rates were also lowered substantially using these techniques. Thus, simple modifications of an existing MUNE program improved the clinical utility of this program for the longitudinal study of patients in whom changes in motor unit number over time are of importance, such as those with motor neuron diseases.
Collapse
Affiliation(s)
- Z Simmons
- Division of Neurology, Pennsylvania State University College of Medicine, Hershey Medical Center, 500 University Drive, Hershey, Pennsylvania 17033-0850, USA.
| | | | | | | | | | | |
Collapse
|
14
|
Abstract
OBJECTIVES To study patients with ALS to determine how physical function, quality of life (QOL), and spirituality or religiousness change over time, and what relationship these changes have to one another. METHODS Sixty patients with ALS were studied prospectively. They were assessed at baseline, 3 months, and 6 months, using questionnaires designed to measure general quality of life (McGill Quality of Life questionnaire), religiosity (Idler Index of Religiosity), ALS-specific health-related quality of life (SIP/ALS-19), and ALS-specific function (ALS functional rating scale). RESULTS A two-way repeated measures multivariate analysis of variance revealed that both the passage of time and the specific QOL scales used were factors in predicting patient quality of life (F[1, 59]= 9.87, p < 0.003 and F[3, 177]= 16.90, p < 0.001) Despite a progressive decline in physical function as measured by the ALS-specific function score, the general QOL and religiosity scores changed little. In contrast, the ALS-specific health-related QOL score declined in parallel with the ALS-specific function score. CONCLUSIONS QOL in patients with ALS appears to be independent of physical function, which agrees with a previous cross-sectional study. The ALS-specific health-related QOL score is primarily a measure of physical function. QOL instruments that assess spiritual, religious, and psychological factors produce different results than those obtained using measures of physical function alone.
Collapse
|
15
|
Abstract
OBJECTIVES To study patients with ALS to determine the following: 1) the relationship between physical function and quality of life (QOL); 2) the instruments that best reflect patients' own ratings of QOL; and 3) whether spiritual/religious factors play a role in determining QOL. METHODS The authors prospectively studied 96 patients with ALS using several instruments, including the McGill Quality of Life (MQOL) instrument, the Idler Index of Religiosity, the Sickness Impact Profile (SIP)/ALS-19, and several measures of strength and physical function. RESULTS QOL as assessed by patients (MQOL single item score) did not correlate with measures of physical function and strength, but correlated with the total MQOL score (p < 0.0005), the psychological and existential subscores of MQOL (p < 0. 0005), the support subscore of MQOL (p = 0.001), and the total Idler score (p = 0.001). In contrast, correlations between SIP/ALS-19 and these measures were not significant, although SIP/ALS-19 correlated with measures of physical function and strength. CONCLUSIONS QOL, as assessed by the patient with ALS, does not correlate with measures of strength and physical function, but appears to depend on psychological and existential factors, and thus may be measured well by the MQOL scale. Spiritual factors and support systems appear to play roles as well. SIP/ALS-19 is a good measure of physical function, but not of overall QOL.
Collapse
Affiliation(s)
- Z Simmons
- Division of Neurology, Pennsylvania State College of Medicine, Hershey 17033, USA.
| | | | | | | | | |
Collapse
|
16
|
Kothari MJ, Heistand M, Simmons Z. Side to side difference of nerve conduction amplitudes. Electromyogr Clin Neurophysiol 2000; 40:81-2. [PMID: 10746182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Affiliation(s)
- M J Kothari
- Division of Neurology, Pennsylvania State University, College of Medicine, Hershey, USA
| | | | | |
Collapse
|
17
|
Abstract
Paraprotein-associated neuropathies are a diverse group of disorders. The pathogenesis of many of them is poorly understood. Treatments have usually consisted of plasma exchange, corticosteroids, intravenous immunoglobulin, and other immunosuppressive therapies. Response to treatment has varied from good to very poor. Most recent work in this field has had two goals: achieving a better understanding of pathogenesis and developing better treatments. Such diverse entities as hepatitis C virus, vascular endothelial growth factor, and cytokines now appear to play a role in pathogenesis. More aggressive therapies such a bone marrow transplantation, interferon-alpha, and Rituximab have shown some promise.
Collapse
Affiliation(s)
- Z Simmons
- Division of Neurology, Penn State University College of Medicine, M.S. Hershey Medical Center, Hershey 17033, USA.
| |
Collapse
|
18
|
Abstract
This study examined the severity of symptoms in carpal tunnel syndrome (CTS) in relation to nerve conduction measures of the median nerve. Clinical symptom severity and nerve conduction studies were evaluated for 64 hands with CTS in 45 patients. We found the following: (1) significant relationships identified among the clinical scales resulted in a dichotomous symptom classification scheme into primary and secondary symptoms, with the former being more specific for those symptoms usually seen in association with nerve injury; (2) there were significant relationships between symptom severity and nerve conduction abnormality; (3) the primary symptom scale correlated more strongly with the electrodiagnostic measures of nerve injury than did the secondary symptom scale. Based on these findings, we believe that these clinical scales have biological significance and reflect median nerve injury. This would support their potential utility for evaluating the outcome of CTS treatment and developing a model for exposure-severity relationship.
Collapse
Affiliation(s)
- H You
- Department of Industrial and Manufacturing Engineering, The Pennsylvania State University, University Park 16802, USA
| | | | | | | | | |
Collapse
|
19
|
Abstract
Four patients with painless, progressive focal neurological deficits that localized to peripheral nerve or plexus were eventually found to have the relatively rare condition of localized hypertrophic neuropathy or intraneural perineurioma. Magnetic resonance imaging (MRI) was an excellent tool for aiding in the precise localization of the lesion, if specifically tailored with regard to imaging planes and specific MRI sequences. Fat-saturated T2-weighted and fat-saturated T1-weighted postgadolinium images provided the best visualization, particularly with a high-field magnet and phase array body coil. Two patients stabilized following resection of the lesion and sural nerve grafting, and 1 had partial improvement in a proximal muscle following neurolysis.
Collapse
Affiliation(s)
- Z Simmons
- Division of Neurology, Penn State College of Medicine, Hershey Medical Center, Pennsylvania 17033, USA
| | | | | | | | | | | |
Collapse
|
20
|
Abstract
OBJECTIVE Electrodiagnostic testing (electromyography [EMG] and nerve conduction studies [NCS]) may result in some patient discomfort. The justification for such testing should be based on the expectation that the results will affect patient management. This study was conducted to determine how frequently the results of EMG/NCS change the clinical management of the patient. METHODS One investigator (MB) spoke to each referring physician after EMG/NCS to determine if any management decisions were altered by the test. RESULTS One hundred forty consecutive EMG/NCS records were obtained. Follow-up was available on 100 patients. Of 78 patients with abnormal findings on EMG/NCS, 29 (37%) had a diagnosis different from the referring diagnosis. For 43 of the 78 (55%), the physician reported that additional diagnostic testing was undertaken or treatment plans were altered. CONCLUSION EMG/NCS are useful, informative, and diagnostic in the management of various neurologic disorders.
Collapse
Affiliation(s)
- M J Kothari
- Section of Neurology, Pennsylvania State University, College of Medicine, Hershey, USA
| | | | | | | | | |
Collapse
|
21
|
Simmons Z, Thornton CA, Seltzer WK, Richards CS. Relative stability of a minimal CTG repeat expansion in a large kindred with myotonic dystrophy. Neurology 1998; 50:1501-4. [PMID: 9596022 DOI: 10.1212/wnl.50.5.1501] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [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: 11/15/2022] Open
Abstract
The genetic basis for myotonic dystrophy (DM) is a CTG trinucleotide repeat expansion. The number of CTG repeats commonly increases in affected individuals of successive generations, in association with anticipation. We identified a large DM family in which multiple members had minimal CTG repeat expansions, and in which the number of CTG repeats remained in the minimally expanded range through at least three, and possibly four, generations. This relative stability of minimal CTG repeat expansions may help to maintain the DM mutation in the population.
Collapse
Affiliation(s)
- Z Simmons
- Division of Neurology, The Pennsylvania State University College of Medicine, Hershey 17033, USA
| | | | | | | |
Collapse
|
22
|
Abstract
We previously reviewed the presentation, initial clinical course, and electrodiagnostic features of children with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). We now report the long-term follow-up of 12 children with idiopathic CIDP, and compare these to 62 adults with idiopathic CIDP. Children often had more rapidly fluctuating courses than adults. A relapsing course was significantly more common in children than in adults. The recovery of children from each episode of deterioration was usually excellent, and better, on average, than in adults. Ventilatory support was never required for children with slowly evolving illness; only 2 children with a precipitous onset clinically resembling Guillain-Barré syndrome required ventilatory support. Prednisone, plasma exchange, and intravenous immunoglobulin (IVIg) usually were effective in children. Multiple courses of IVIg could be given with continued efficacy. Treatment often could be discontinued in children with relapsing courses. The prognosis for children was excellent. Adults demonstrated a good, but more variable, outcome.
Collapse
Affiliation(s)
- Z Simmons
- Division of Neurology, The Pennsylvania State University College of Medicine, Hershey Medical Center, 17033, USA
| | | | | |
Collapse
|
23
|
|
24
|
Simmons Z, Wald JJ, Albers JW. Chronic inflammatory demyelinating polyradiculoneuropathy in children: I. Presentation, electrodiagnostic studies, and initial clinical course, with comparison to adults. Muscle Nerve 1997; 20:1008-15. [PMID: 9236792 DOI: 10.1002/(sici)1097-4598(199708)20:8<1008::aid-mus11>3.0.co;2-r] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [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: 02/04/2023]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is rare in children. We reviewed features of 15 children with idiopathic CIDP, and compared these to 69 adults with idiopathic CIDP. Children demonstrated many similarities to adults: (1) Antecedent events were uncommon. (2) There was a high frequency of weakness and reflex loss, a relatively high frequency of sensory loss, and a low frequency of pain and cranial neuropathies. (3) Cerebrospinal fluid protein levels were usually elevated. (4) On electrodiagnostic testing, not all nerve segments were abnormal, and not all children satisfied electrodiagnostic criteria for CIDP. Children differed from adults with CIDP in several ways: (1) The onset of symptoms was usually more precipitous. (2) Gait abnormalities were a more frequent presenting symptom. (3) Children always presented with significant neurological dysfunction, and not with the minor symptoms initially seen in some adults. The initial response of children with CIDP to immunomodulating therapy was excellent.
Collapse
Affiliation(s)
- Z Simmons
- Division of Neurology, Pennsylvania State University College of Medicine, Hershey Medical Center, Hershey 17033, USA
| | | | | |
Collapse
|
25
|
Thornton CA, Wymer JP, Simmons Z, McClain C, Moxley RT. Expansion of the myotonic dystrophy CTG repeat reduces expression of the flanking DMAHP gene. Nat Genet 1997; 16:407-9. [PMID: 9241283 DOI: 10.1038/ng0897-407] [Citation(s) in RCA: 165] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Myotonic dystrophy, or dystrophia myotonica (DM), is a highly variable multisystem disease in which the classic adult-onset form displays progressive muscle wasting, cataracts, heart block, gonadal atrophy, insulin resistance and neuropsychiatric impairment. Its genetic basis is an expansion of CTG trinucleotide repeats in the DMPK protein kinase gene. Among the triplet repeat expansion disorders, DM is distinguished by the extended length of the repeat tract (5-13 kb in postmortem tissue) and its location in the 3' untranslated region of the gene that contains it. The pathophysiological mechanism for multisystem degeneration in DM is not understood. In contrast to the profound muscle wasting that characterizes advanced DM, only minor histopathological abnormalities have occurred in DMPK knockout mice or in mice that overexpress a human DMPK transgene, making it unlikely that changes in DMPK activity provide a unitary explanation for the disease. A DNAse hypersensitive site that maps 0.7 kb downstream (centromeric) from the CTG repeats is eliminated on DM chromosomes. This finding indicates that the repeat expansion may alter the adjacent chromatin structure and raises the possibility that it may also affect the expression of flanking genes. An interesting candidate flanking gene is DMAHP, a recently discovered homeodomain-encoding gene. We show here that DMAHP expression in myoblasts, muscle and myocardium is reduced by the DM mutation is cis, and the magnitude of this effect depends on the extent of CTG repeat expansion. These observations support the hypothesis that DMAHP participates in the pathophysiology of DM.
Collapse
Affiliation(s)
- C A Thornton
- Department of Neurology, School of Medicine and Dentistry, University of Rochester, NY 14642, USA
| | | | | | | | | |
Collapse
|
26
|
Affiliation(s)
- Z Simmons
- Division of Neurology, Pennsylvania State University College of Medicine, Hershey 17033, USA
| | | |
Collapse
|
27
|
Abstract
Eight elderly men whose primary symptoms of myasthenia gravis were decreased speech and swallowing ability were seen for speech pathology evaluations and videofluoroscopic swallow studies. All patients had fatigable flaccid dysarthria and greater than expected pharyngeal phase dysphagia on videofluoroscopy; eight had decreased pharyngeal motility as demonstrated by residual material in the valleculae and pyriform sinuses bilaterally; seven had episodes of laryngeal penetration secondary to overflow of residual material; and five experienced silent aspiration despite gag reflexes and the ability to cough to command. Five patients required feeding tubes because their dysphagia responded poorly to treatment. Videofluoroscopic swallow studies revealed a common swallowing profile with pharyngeal phase dysphagia greater than expected from patient symptoms. Dysphagia did not improve at the same rate as other manifestations of myasthenia gravis.
Collapse
Affiliation(s)
- K J Kluin
- Department of Neurology, University of Michigan Medical Center, 1H243 University Hospital, Ann Arbor 48109-0050, USA
| | | | | | | |
Collapse
|
28
|
Doherty T, Simmons Z, O'Connell B, Felice KJ, Conwit R, Chan KM, Komori T, Brown T, Stashuk DW, Brown WF. Methods for estimating the numbers of motor units in human muscles. J Clin Neurophysiol 1995; 12:565-84. [PMID: 8600172 DOI: 10.1097/00004691-199511000-00004] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.4] [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: 01/31/2023] Open
Abstract
After the introduction by A. J. McComas of the original method for estimating the number of motor units based on manual incremental stimulation of a motor nerve, several new techniques have been developed, designed to correct for some of the errors inherent in the original technique. These methods incorporate algorithms to adjust for alternation and, to a greater or lesser extent, automate the methods, rendering the techniques less subject to operator bias and various physiological and technical errors. This review explores the advantages and drawbacks in the multiple-point stimulation (MPS), spike-triggered averaging (STA), and decomposition-enhanced STA techniques, illustrates some of the current applications of the techniques, and explores some tantalizing prospects for new studies of motor-unit physiology in the future.
Collapse
Affiliation(s)
- T Doherty
- Faculty of Kinesiology, University of Western Ontario, London, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Simmons Z, Albers JW, Bromberg MB, Feldman EL. Long-term follow-up of patients with chronic inflammatory demyelinating polyradiculoneuropathy, without and with monoclonal gammopathy. Brain 1995; 118 ( Pt 2):359-68. [PMID: 7735878 DOI: 10.1093/brain/118.2.359] [Citation(s) in RCA: 108] [Impact Index Per Article: 3.7] [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: 01/26/2023] Open
Abstract
We previously demonstrated differences in presentation and initial clinical course between patients with idiopathic chronic inflammatory demyelinating polyradiculoneuropathy (CIDP-I) and those in whom CIDP was associated with a monoclonal gammopathy of undetermined significance (CIDP-MGUS). We now report the long-term follow-up of 69 patients with CIDP-I and 25 patients with CIDP-MGUS. (i) The clinical course was progressive in most of the CIDP-MGUS patients. CIDP-I patients were more likely to have a monophasic or relapsing course. (ii) Impairment developed more slowly in CIDP-MGUS than CIDP-I patients, with a longer time from onset of deterioration to peak impairment for each episode. (iii) Patients with CIDP-MGUS experienced less severe functional impairment and a lesser degree of measured weakness during their worst episode than did patients with CIDP-I. The primary source of functional impairment in many CIDP-MGUS patients was sensory. In contrast, the deficits in most patients with CIDP-I were primarily motor. (iv) CIDP-MGUS patients experienced a smaller degree of improvement to a poorer functional level after each episode than did patients with CIDP-I. (v) Most patients had a good outcome. However, the strength and functional scores at the time of last follow-up were significantly poorer in CIDP-MGUS than in CIDP-I patients. (vi) The disease was reclassified in seven patients; some patients with CIDP-I developed an MGUS, while some with CIDP-I or CIDP-MGUS developed multiple myeloma or a related malignant lymphoproliferative disease. These findings have implications for patient counselling and long-term prognosis, and underscore the need for long-term clinical and immunological monitoring.
Collapse
Affiliation(s)
- Z Simmons
- Division of Neurology, Pennsylvania State University College of Medicine, Hershey 17033, USA
| | | | | | | |
Collapse
|
30
|
Simmons Z, Wald J, Albers JW, Feldman EL. The natural history of a "benign" rib lesion in a patient with a demyelinating polyneuropathy and an unusual variant of POEMS syndrome. Muscle Nerve 1994; 17:1055-9. [PMID: 8065392 DOI: 10.1002/mus.880170913] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [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: 01/28/2023]
Abstract
Patients with POEMS (polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes) syndrome exhibit great clinical variability and often have osteosclerotic myeloma. We present a patient with an acquired demyelinating polyneuropathy who was eventually diagnosed as having POEMS syndrome. Her long period of observation permitted documentation of the natural history of a plasmacytoma, including its remarkably slow rate of growth and its transformation from a nonsclerotic to a sclerotic bone lesion. Her clinical and laboratory features emphasize the variability of this syndrome. Biopsy of benign-appearing bone lesions should be considered in patients with acquired demyelinating polyneuropathies who do not respond to standard treatment modalities. Serial x-rays may not distinguish benign lesions from plasmacytomas in this treatable condition.
Collapse
Affiliation(s)
- Z Simmons
- Division of Neurology, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey 17033
| | | | | | | |
Collapse
|
31
|
Simmons Z, Blaivas M, Aguilera AJ, Feldman EL, Bromberg MB, Towfighi J. Low diagnostic yield of sural nerve biopsy in patients with peripheral neuropathy and primary amyloidosis. J Neurol Sci 1993; 120:60-3. [PMID: 7507161 DOI: 10.1016/0022-510x(93)90025-t] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.7] [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: 01/25/2023]
Abstract
Patients with primary amyloidosis may develop peripheral neuropathy as an early feature. Sural nerve biopsy is reported to be a sensitive method for diagnosing amyloidosis in such patients. We identified nine patients, ultimately diagnosed as having amyloidosis, who were referred for peripheral neuropathy of undetermined etiology. In six, a sural nerve biopsy demonstrated no amyloid. Subsequent examination of other tissue or of the contralateral sural nerve eventually resulted in the correct diagnosis. We conclude that sural nerve biopsy may be less sensitive than previously believed for the diagnosis of amyloidosis in patients with peripheral neuropathy secondary to amyloid. When the clinical suspicion of amyloidosis is high, a nondiagnostic sural nerve biopsy should not discourage the performance of further investigative studies.
Collapse
Affiliation(s)
- Z Simmons
- Department of Neurology, University of Michigan, Ann Arbor 48109
| | | | | | | | | | | |
Collapse
|
32
|
Simmons Z, Albers JW, Bromberg MB, Feldman EL. Presentation and initial clinical course in patients with chronic inflammatory demyelinating polyradiculoneuropathy: comparison of patients without and with monoclonal gammopathy. Neurology 1993; 43:2202-9. [PMID: 8232929 DOI: 10.1212/wnl.43.11.2202] [Citation(s) in RCA: 125] [Impact Index Per Article: 4.0] [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: 01/29/2023] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) may occur in association with a monoclonal gammopathy of undetermined significance (MGUS) or a variety of other systemic illnesses. It is not known if the clinical features of CIDP are altered by the presence of an MGUS. We compared demographic features, clinical presentation, improvement and outcome after initial treatment, and electrodiagnostic features of a group of 77 patients with idiopathic CIDP (CIDP-I, no associated systemic illness) with 26 patients with CIDP in whom an MGUS was found during evaluation of the neuropathy (CIDP-MGUS). Patients with CIDP-MGUS had, on average, a more indolent course and less severe weakness than patients with CIDP-I, despite similar motor conduction studies. CIDP-MGUS patients also demonstrated less functional impairment, more frequent sensory loss, and more abnormal sensory conduction studies than patients with CIDP-I. Because of the greater improvement of CIDP-I patients with treatment, both groups had similar outcomes from their initial episodes of weakness. Subgroup analysis of CIDP-MGUS patients did not demonstrate differences between groups with IgM and IgG or IgA gammopathies.
Collapse
Affiliation(s)
- Z Simmons
- Division of Neurology, Pennsylvania State University College of Medicine, Hershey 17033
| | | | | | | |
Collapse
|
33
|
Bromberg MB, Forshew DA, Nau KL, Bromberg J, Simmons Z, Fries TJ. Motor unit number estimation, isometric strength, and electromyographic measures in amyotrophic lateral sclerosis. Muscle Nerve 1993; 16:1213-9. [PMID: 8413373 DOI: 10.1002/mus.880161111] [Citation(s) in RCA: 90] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Pathologic progression in amyotrophic lateral sclerosis (ALS) results from motor neuron death, while the clinical expression also reflects the compensatory effects of collateral reinnervation consequent to lower motor neuron loss. In a cross-sectional study of ALS subjects, we made comparisons between motor unit number estimation (MUNE) values and several measures reflecting collateral reinnervation, including isometric strength, compound muscle action potential (CMAP) amplitude, surface motor unit action potential (S-MUAP) amplitude, fiber density (FD), macro-EMG potential amplitude, turns-to-amplitude (T/A) ratio, and amplitude and recruitment pattern of low threshold voluntary motor units in elbow flexor muscles. Before comparisons were made, test-retest reproducibility of these measures was assessed in ALS subjects, and is highest for isometric strength, and lower but similar for EMG measures. When the effects of multiple comparisons are considered, borderline significant correlations are found between MUNE values and isometric strength. Neither MUNE values nor isometric strength are significantly correlated with macro-EMG amplitude, FD, T/A ratio, or amplitude and recruitment rate of low threshold voluntary motor units. There are significant correlations of CMAP and S-MUAP with MUNE values, but these are statistical artifacts with no independent interpretation. We conclude that collateral reinnervation prevents isometric strength and EMG measures from accurately reflecting lower motor neuron death in ALS. MUNE measurements are better suited to provide insight into the true natural history of the disease process and may be clinically useful to follow progression and response in drug trials.
Collapse
Affiliation(s)
- M B Bromberg
- Department of Neurology, University of Michigan, Ann Arbor
| | | | | | | | | | | |
Collapse
|
34
|
Abstract
Although polyneuropathies associated with IgM and IgG monoclonal gammopathies have been well described, polyneuropathy with IgA monoclonal gammopathy of undetermined significance (MGUS) is less commonly seen and has not been well studied. We reviewed the clinical and electrodiagnostic features of 5 such patients, and the sural nerve biopsy findings in 4 of them. One patient was diabetic, while 4 were free of other diagnoses commonly associated with neuropathy. Clinical presentations were varied. Electrodiagnostic and histological studies ranged from primary demyelination to primary axon loss to a mixed axonal/demyelinating picture. Three patients who were treated appeared to respond to prednisone or intravenous gamma globulin, despite clear clinical, electrodiagnostic, and histological differences. We conclude that the polyneuropathy associated with IgA MGUS is heterogeneous, similar to that in IgM and IgG MGUS. A trial of immunomodulating therapy appears to be warranted in such patients if the neuropathy is sufficiently severe.
Collapse
Affiliation(s)
- Z Simmons
- Department of Neurology, University of Michigan, Ann Arbor
| | | | | | | |
Collapse
|
35
|
Abstract
Perineuritis unassociated with other significant pathological changes is a rare finding. A patient is described with mild, non-insulin dependent diabetes mellitus who presented with the clinical picture of mononeuritis multiplex, and in whom perineuritis but no occlusive vascular disease was found on sural nerve biopsy. Treatment with prednisone and plasma exchange resulted in some improvement. We conclude that the focal perineuritis, rather than the diabetes, was responsible for the clinical picture mimicking mononeuritis multiplex. In conjunction with previous reports, this suggests that perineuritis may be a treatable neuropathy.
Collapse
Affiliation(s)
- Z Simmons
- Department of Neurology, University of Michigan, Ann Arbor
| | | | | |
Collapse
|
36
|
Abstract
Five patients who presented with clearly defined thoracic sensory levels were found by myelography and follow-up computed tomography (CT) to have cervical spinal cord compression. None of these patients had pain or an immediate preceding history of trauma. There is currently no satisfactory explanation for the large discrepancy between the sensory level and the level of cord compression in such patients. It is crucial that the clinician recognize the possibility of a cervical cord lesion in patients with such a presentation so that appropriate radiographic studies can be performed. Failure to appreciate this syndrome could result in failure to diagnose a treatable lesion.
Collapse
|
37
|
Biller J, Adams HP, Dunn V, Simmons Z, Jacoby CG. Dichotomy between clinical findings and MR abnormalities in pontine infarction. J Comput Assist Tomogr 1986; 10:379-85. [PMID: 3700737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Comparison between cranial CT and magnetic resonance (MR) imaging in 10 patients with recent pontine infarction indicates a distinct superiority for MR. However, MR changes often failed to correlate with the degree of neurological dysfunction. Regions of abnormal signal intensity appeared to involve areas with normal neurologic function.
Collapse
|
38
|
Simmons Z, Biller J, Adams HP, Dunn V, Jacoby CG. Cerebellar infarction: comparison of computed tomography and magnetic resonance imaging. Ann Neurol 1986; 19:291-3. [PMID: 3963774 DOI: 10.1002/ana.410190312] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We correlated clinical, computed tomographic (CT), and magnetic resonance imaging (MRI) findings in 14 patients with cerebellar infarctions. Before MRI, the diagnosis of cerebellar infarction was made in only 7 patients on the basis of clinical and CT evidence. Cerebellar infarction was bilateral in 3 patients and was associated with brainstem infarction in 6. Infarction occurred in the territory of the posterior inferior cerebellar artery (PICA) in 12 patients. The territory of the superior cerebellar artery (SCA) was involved in 1 patient, and 1 infarction encompassed the watershed between the PICA and the SCA. In patients with infarction of the PICA territory, the medial and intermediate hemispheric segments were most frequently involved. Involvement of the lateral hemispheric segment was infrequent and was independent of brainstem involvement. Because of its fine demonstration of anatomical detail, its lack of bony artifact, and its ability to visualize infarctions readily within the first 24 hours, MRI is an excellent method for demonstrating cerebellar infarction.
Collapse
|
39
|
Trumpower BL, Simmons Z. Diminished inhibition of mitochondrial electron transfer from succinate to cytochrome c by thenoyltrifluoroacetone induced by antimycin. J Biol Chem 1979; 254:4608-16. [PMID: 220256] [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: 12/13/2022] Open
|
40
|
Trumpower B, Simmons Z. Diminished inhibition of mitochondrial electron transfer from succinate to cytochrome c by thenoyltrifluoroacetone induced by antimycin. J Biol Chem 1979. [DOI: 10.1016/s0021-9258(17)30054-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
41
|
Lusby AF, Simmons Z, McGuire PM. Variation in mutagenicity of s-triazine compounds tested on four Salmonella strains. Environ Mutagen 1979; 1:287-90. [PMID: 399912 DOI: 10.1002/em.2860010312] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|