scholarly journals Prospective international validation of the predisposition, infection, response and organ dysfunction (PIRO) clinical staging system among intensive care and general ward patients

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
T. Cardoso ◽  
P. P. Rodrigues ◽  
C. Nunes ◽  
M. Almeida ◽  
J. Cancela ◽  
...  
Keyword(s):  
Intensive Care ◽  
Organ Dysfunction ◽  
Stage Iv ◽  
Staging System ◽  
Stage I ◽  
Stage Iii ◽  
Disease Stage ◽  
Clinical Staging ◽  
Operating Characteristics ◽  
Infection Response

Abstract Background Stratifying patients with sepsis was the basis of the predisposition, infection, response and organ dysfunction (PIRO) concept, an attempt to resolve the heterogeneity in treatment response. The purpose of this study is to perform an independent validation of the PIRO staging system in an international cohort and explore its utility in the identification of patients in whom time to antibiotic treatment is particularly important. Methods Prospective international cohort study, conducted over a 6-month period in five Portuguese hospitals and one Australian institution. All consecutive adult patients admitted to selected wards or the intensive care, with infections that met the CDC criteria for lower respiratory tract, urinary, intra-abdominal and bloodstream infections were included. Results There were 1638 patients included in the study. Patients who died in hospital presented with a higher PIRO score (10 ± 3 vs 8 ± 4, p < 0.001). The observed mortality was 3%, 15%, 24% and 34% in stage I, II, III and IV, respectively, which was within the predicted intervals of the original model, except for stage IV patients that presented a lower mortality. The hospital survival rate was 84%. The application of the PIRO staging system to the validation cohort resulted in a positive predictive value of 97% for stage I, 91% for stage II, 85% for stage III and 66% for stage IV. The area under the receiver operating characteristics curve (AUROC) was 0.75 for the all cohort and 0.70 if only patients with bacteremia were considered. Patients in stage III and IV who did not have antibiotic therapy administered within the desired time frame had higher mortality rate than those who have timely administration of antibiotic. Conclusions To our knowledge, this is the first external validation of this PIRO staging system and it performed well on different patient wards within the hospital and in different types of hospitals. Future studies could apply the PIRO system to decision-making about specific therapeutic interventions and enrollment in clinical trials based on disease stage.

Clinical Staging for Sleep-Disordered Breathing

2002 ◽  
Vol 127 (1) ◽  
pp. 13-21 ◽  
Author(s):  
Michael Friedman ◽  
Hani Ibrahim ◽  
Lee Bass
Keyword(s):  
Body Mass Index ◽  
Success Rate ◽  
Body Mass ◽  
Sleep Disordered Breathing ◽  
Staging System ◽  
Stage I ◽  
Stage Ii ◽  
Stage Iii ◽  
Clinical Staging ◽  
Disordered Breathing

OBJECTIVE: The purpose of this study was to identify prognostic indicators that would lead to stratification of patients likely to have successful surgery for sleep-disordered breathing (SDB) versus those destined to fail. STUDY DESIGN: We retrospectively reviewed 134 patients to correlate palate position and tonsil size to the success of the UPPP as based on postoperative polysomnography results. Similar to our previously published data on the Friedman Score as a predictor of the presence and severity of SDB, the palate position was determined on physical examination of the oral cavity and was graded for each patient. This grade combined with tonsil size was used to stage the patients. Stage I was defined as having palate position 1 or 2 combined with tonsil size 3 or 4. Stage II was defined as having palate position 3 or 4 and tonsil size 3 or 4. Stage III patients had palate position 3 or 4 and tonsil size 0, 1, or 2. Any patient with body mass index of greater than 40 was placed in the stage III group. The results of uvulopalatopharyngoplasty (UPPP) were then graded as success or failure and success rates were compared by stage. SETTING: Academically affiliated tertiary care referral center. RESULTS: Stage I patients who underwent UPPP had a success rate of 80.6%, stage II patients had a success rate of 37.9%, and stage III patients had a success rate of 8.1%. CONCLUSION: A clinical staging system for SDB based on palate position, tonsil size, and body mass index is presented. It appears to be a valuable predictor of the success of UPPP. Additional studies and wider use of the staging system will ultimately define its role in the treatment of SDB.

scholarly journals International Study of Primary Mucinous Ovarian Carcinomas Managed at Tertiary Medical Centers

2018 ◽  
Vol 28 (5) ◽  
pp. 915-924 ◽  
Author(s):  
Jennifer J. Mueller ◽  
Henrik Lajer ◽  
Berit Jul Mosgaard ◽  
Slim Bach Hamba ◽  
Philippe Morice ◽  
...  
Keyword(s):  
Early Stage ◽  
Statistical Tests ◽  
Stage Iv ◽  
Stage I ◽  
Stage Iii ◽  
Oncologic Outcomes ◽  
Disease Stage ◽  
Ovarian Carcinomas ◽  
Early Stage Disease ◽  
Medical Centers

ObjectiveWe sought to describe a large, international cohort of patients diagnosed with primary mucinous ovarian carcinoma (PMOC) across 3 tertiary medical centers to evaluate differences in patient characteristics, surgical/adjuvant treatment strategies, and oncologic outcomes.MethodsThis was a retrospective review spanning 1976–2014. All tumors were centrally reviewed by an expert gynecologic pathologist. Each center used a combination of clinical and histologic criteria to confirm a PMOC diagnosis. Data were abstracted from medical records, and a deidentified dataset was compiled and processed at a single institution. Appropriate statistical tests were performed.ResultsTwo hundred twenty-two patients with PMOC were identified; all had undergone primary surgery. Disease stage distribution was as follows: stage I, 163 patients (74%); stage II, 8 (4%); stage III, 40 (18%); and stage IV, 10 (5%). Ninety-nine (45%) of 219 patients underwent lymphadenectomy; 41 (19%) of 215 underwent fertility-preserving surgery. Of the 145 patients (65%) with available treatment data, 68 (47%) had received chemotherapy—55 (81%) a gynecologic regimen and 13 (19%) a gastrointestinal regimen. The 5-year progression-free survival (PFS) rates were 80% (95% confidence interval [CI], 73%–85%) for patients with stage I to II disease and 17% (95% CI, 8%–29%) for those with stage III to IV disease. The 5-year PFS rate was 73% (95% CI, 50%–86%) for patients who underwent fertility-preserving surgery.ConclusionsMost patients (74%) presented with stage I disease. Nearly 50% were treated with adjuvant chemotherapy using various regimens across institutions. The PFS outcomes were favorable for those with early-stage disease and lower but acceptable for those who underwent fertility preservation.

Clinical pathways implementation in a community-based oncology practice: Real-world outcomes in patients with non-small cell lung cancer segmented by disease stage at diagnosis.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e18719-e18719
Author(s):  
Natalie R. Dickson ◽  
Karen Beauchamp ◽  
Toni S. Perry ◽  
Ashley Roush ◽  
Deborah Goldschmidt ◽  
...  
Keyword(s):  
Treatment Initiation ◽  
Clinical Pathways ◽  
Stage Iv ◽  
Treatment Patterns ◽  
Stage I ◽  
Stage Iii ◽  
Disease Stage ◽  
Stage At Diagnosis ◽  
Small Cell Lung ◽  
Stage Iv Disease

e18719 Background: Clinical pathways have been introduced as tools to optimize cancer care delivery, but evidence of their value in the real world is limited. This retrospective study was performed to assess treatment patterns and clinical outcomes in patients with non-small cell lung cancer (NSCLC) before and after pathway implementation at Tennessee Oncology (TO). Methods: Chart data were abstracted for patients (≥18 years) diagnosed with Stage I-IV NSCLC who initiated first-line (1L) systemic treatment at a TO clinic and had follow-up for ³6 months or until death. Patients were divided into two cohorts: pre-pathways (treatment initiation 2014–2015) and post-pathways (treatment initiation 2016–2018). Patient characteristics, treatment patterns, and outcomes were described and compared across cohorts. An exploratory study endpoint was the evaluation of outcomes based on disease stage at diagnosis. Results: Among 501 patients (251 pre-pathways and 250 post-pathways), most had advanced or metastatic NSCLC at diagnosis (Stage III: 40%; Stage IV: 42%). Chemotherapy comprised almost all 1L systemic therapy used pre-pathways (Stage I/II: 100%; Stage III: 96%; Stage IV: 83%). Post-pathways, chemotherapy remained the most common 1L therapy in patients with Stage I/II (89%) and Stage III (72%) disease, but among patients with Stage IV disease, use of chemotherapy decreased (47%) and immuno-oncology (IO) therapy alone or in combination became common (45%). Median duration of 1L therapy was longer post-pathways in patients with Stage III (2.1 months vs 1.4 months pre-pathways; P < 0.01) and Stage IV disease (3.3 months vs 2.3 months pre-pathways; P < 0.01) but did not differ among Stage I/II patients. Median progression-free survival was significantly longer post-pathways in patients with Stage IV disease (7.0 months vs 4.2 months pre-pathways; P < 0.05), but not in other disease-stage subgroups. Median overall survival increased non-significantly post-pathways for all disease stage subgroups (Stage I/II: 26 months vs 20 months pre-pathways; Stage III: 26 months vs 20 months; Stage IV: 10 months vs 9 months). For each disease stage, rates of severe adverse events were similar between cohorts. Conclusions: While outcomes for patients diagnosed with Stage III/IV NSCLC were generally improved following the implementation of clinical pathways, this change coincided with a dramatic shift in available treatment options. Improvements post-pathways were mainly observed in patients diagnosed with advanced disease. Thus, differences in outcomes between pre-pathways and post-pathways cohorts in our study are more likely attributable to other evolving practices in cancer care, particularly the availability of newer, more effective treatments such as IO therapy as part of standard practice, than implementation of the clinical pathways.

Non-Hodgkin's lymphomas of childhood: an analysis of the histology, staging, and response to treatment of 338 cases at a single institution.

1989 ◽  
Vol 7 (2) ◽  
pp. 186-193 ◽  
Author(s):  
S B Murphy ◽  
D L Fairclough ◽  
R E Hutchison ◽  
C W Berard
Keyword(s):  
Cox Regression ◽  
Specific Treatment ◽  
Stage Iv ◽  
Stage I ◽  
Stage Ii ◽  
Stage Iii ◽  
Response To Treatment ◽  
Clinical Staging ◽  
Prognostic Indicators ◽  
Hodgkin's Lymphomas

Between 1962 and 1986, a total of 338 consecutive newly diagnosed children and adolescents with non-Hodgkin's lymphomas (NHLs) were evaluated and treated at St Jude Children's Research Hospital (SJCRH). Median follow-up is 6.6 years (range, 1.8 to 23 years). The patients ranged in age from 7 months to 21 years (median, 10 years), and 71% were males. All cases were staged (I to IV) by a clinical staging system. Eighteen percent were stage I, 21% stage II, 43% stage III, and 18% stage IV. Cases frankly leukemic at diagnosis (ie, greater than 25% marrow blasts) were excluded from the analysis. Pathologic material from all cases was reviewed and classified according to the Working Formulation. The histologic distribution of cases was as follows: 38.8% diffuse small non-cleaved cell (undifferentiated, Burkitt's and non-Burkitt's); 26.3% diffuse large-cell, mainly immunoblastic; 28.1% lymphoblastic; and 6.8% other. Treatment policy evolved over time to a stage- and histology-specific strategy for treatment assignment, and overall results significantly improved by era from 37% (+/- 5%) 2-year event-free survival (EFS) for patients treated before 1975 to 77% (+/- 4%) since 1978. By univariate and multivariate Cox regression analyses, the era of treatment (hence, the protocol-specific treatment itself), the stage, and the log of the initial serum lactic dehydrogenase (LDH) emerged as the most powerful prognostic indicators, while histology per se was not significantly related to outcome. For the 154 patients treated since 1978, the 2-year EFS by stage was 97% (+/- 3%) for stage I, 86% (+/- 6%) for stage II, 73% (+/- 6%) for stage III, and 47% (+/- 11%) for stage IV (P less than .0001). Compared with our previous experience, we conclude that the cure rate of childhood NHL has doubled in the last decade with modern management.

scholarly journals Clinical staging of chronic lymphocytic leukemia

Blood ◽  
1975 ◽  
Vol 46 (2) ◽  
pp. 219-234 ◽  
Author(s):  
KR Rai ◽  
A Sawitsky ◽  
EP Cronkite ◽  
AD Chanana ◽  
RN Levy ◽  
...  
Keyword(s):  
Chronic Lymphocytic Leukemia ◽  
Median Survival ◽  
Prognostic Significance ◽  
Stage Iv ◽  
Staging System ◽  
Lymphocytic Leukemia ◽  
Stage Ii ◽  
Stage Iii ◽  
Clinical Staging ◽  
Survival Times

A method of clinical staging of chronic lymphocytic leukemia (CLL) has been proposed which is based on the concept that CLL is a disease of progressive accumulation of nonfunctioning lymphocytes: stage O, bone marrow and blood lymphocytosis only; stage 1, lymphocytosis with enlarged nodes; stage II, lymphocytosis with enlarged spleen or liver or both; stage III, lymphocytosis with anemia; and stage IV:lymphocytosis with thrombocytopenia. Analysis of 125 patients. in the present series showed the following median survival times (in months) from diagnosis: stage 0, is greater than 150; stage I 101; stage II, 71; stage III, 19; stage IV, 19, The median survival for the entire series was 71 mo. The prognostic significance of the stage remained even after adjustment was made for age and sex. However, both sex and age were shown to be poor predictors of survival after adjustment for stage. The method of staging proved to be a reliable predictor of survival whether used at diagnosis or during the course of the disease. The proposed staging system was an equally accurate indicator for survival when applied to two other previously published studies of large series of patients.

Results of a stage-based protocol for the treatment of retinoblastoma.

1996 ◽  
Vol 14 (5) ◽  
pp. 1532-1536 ◽  
Author(s):  
E Schvartzman ◽  
G Chantada ◽  
A Fandiño ◽  
M T de Dávila ◽  
E Raslawski ◽  
...  
Keyword(s):  
Overall Survival ◽  
Optic Nerve ◽  
Stage Iv ◽  
Stage I ◽  
Stage Ii ◽  
Stage Iii ◽  
Disease Stage ◽  
Hematogenous Metastasis ◽  
Intrathecal Therapy ◽  
Orbital Mass

PURPOSE To describe the treatment of retinoblastoma at a single institution using a prospective protocol based on histopathologic staging. PATIENTS AND METHODS We included 116 consecutive patients (101 eligible, 46 bilateral) from August 1987 to December 1993. Treatment was enucleation or conservative therapy for intraocular disease (stage I patients). Stage II patients (orbital or postlaminar invasion) received vincristine, cyclophosphamide, and doxorubicin for 57 weeks. Patients with orbital mass and extension beyond the cut end of the optic nerve also received orbital radiotherapy (45 Gy). The latter received intrathecal therapy. In those with CNS (stage III) or hematogenous metastasis (stage IV), cisplatin and etoposide were added along with cranial (in patients with a CNS mass and prophylactically in stage IV) or craniospinal (in patients with positive CSF) radiotherapy. RESULTS The median follow-up time was 39 months (range, 12 to 84). The overall survival rate was 0.84. Survival rates according to stage were as follows: stage I probability of overall survival [pOS] = 0.97) (alive/total), 59 of 60; stage II (pOS = 0.85) including patients with scattered episcleral cells, three of three; orbital mass, one of one; postlaminar invasion up to and beyond the cut end of optic nerve, 10 of 11 and 11 of 14, respectively; of stage III (pOS = 0), zero of six; and stage IV (pOS = 0.50), three of six. Only those patients with preauricular adenopathy as the only metastatic site survived in the latter group. Acute toxicity was mild. CONCLUSION Chemotherapy is not warranted to prevent systemic metastasis for intraocular disease. Patients with extraocular orbital disease and had a good outcome with this therapy. Patients with metastatic disease fared poorly, except for those with isolated malignant preauricular adenopathy.

Asbestos-related malignant mesothelioma in Japan

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 18182-18182
Author(s):  
T. Kishimoto
Keyword(s):  
Malignant Mesothelioma ◽  
Asbestos Exposure ◽  
Stage Iv ◽  
Final Diagnosis ◽  
Best Supportive Care ◽  
Stage I ◽  
Stage Iii ◽  
Clinical Staging ◽  
Tumor Tissues ◽  
The Mean

18182 Large amounts of asbestos use from 1960’s induced the increase of death caused by malignant mesothelioma in Japan. However, a national survey of the relationship between malignant mesothelioma and asbestos exposure, as well as diagnosis and treatment of malignant mesothelioma has not done up to today. One hundred and fifty-three cases of malignant mesothelioma diagnosed and treated in the Rosai Hospitals located all over Japan were studied, and 132 cases (80.4%) proved to be the definite diagnosis of malignant mesothelioma; another 21 cases were diagnosed as lung cancer, etc. As for definite 132 cases, 105 cases are male and other 27 cases are female with the ratio of 3.9:1. Ages ranges from 28 to 92 years old with the mean of 66.2 years old. One hundred and twelve cases originated from pleura, 18 cases from peritoneum, and each one case originated from pericardium and testicular tunica vaginalis. Final diagnosis of 104 cases (78.8%) was done by the tumor tissues. According to IMIG classification, stage I was 29 cases, stage II 6 cases, stage III 28 cases and stage IV was 44 cases. For the treatment, 29 cases were done extrapleurectomy, 58 cases were chemotherapy and other 39 cases were best supportive care. Median survival term of 132 cases were 9.5 months with 9.8 months of pleural origin and 5.6 months of peritoneal origin. By the clinical staging, stage I and II were 17.2 months, stage III 10.4 months and stage IV 5.4 months. By the treatment, extrapleurectomy was 18.1 months, chemotherapy 8.0 months and palliative care was 5.7 months. Seventy six percent cases were induced by occupational asbestos exposure and the mean exposuring time was 27.6 years and the mean latency was 43 years. Occupational histories were mainly shipbuilders, carpenters, electricians and piping workers. Summary: Seventy-six percent of Japanese malignant mesothelioma appeared by the occupational exposure to asbestos. Seventy-eight percent of final diagnosis were done by histological examination of tumor tissue. Extrapleurectomy was effective for the prognosis. [Table: see text] No significant financial relationships to disclose.

scholarly journals Predisposition, Insult/Infection, Response and Organ Dysfunction (PIRO): A Pilot Clinical Staging System for Hospital Mortality in Patients with Infection

PLoS ONE ◽  
2013 ◽  
Vol 8 (7) ◽  
pp. e70806 ◽  
Author(s):  
Teresa Cardoso ◽  
Armando Teixeira-Pinto ◽  
Pedro Pereira Rodrigues ◽  
Irene Aragão ◽  
Altamiro Costa-Pereira ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Organ Dysfunction ◽  
Staging System ◽  
Clinical Staging ◽  
Infection Response ◽  
Clinical Staging System

scholarly journals Clinical staging of chronic lymphocytic leukemia

Blood ◽  
1975 ◽  
Vol 46 (2) ◽  
pp. 219-234 ◽  
Author(s):  
KR Rai ◽  
A Sawitsky ◽  
EP Cronkite ◽  
AD Chanana ◽  
RN Levy ◽  
...  
Keyword(s):  
Chronic Lymphocytic Leukemia ◽  
Median Survival ◽  
Prognostic Significance ◽  
Stage Iv ◽  
Staging System ◽  
Lymphocytic Leukemia ◽  
Stage Ii ◽  
Stage Iii ◽  
Clinical Staging ◽  
Survival Times

Abstract A method of clinical staging of chronic lymphocytic leukemia (CLL) has been proposed which is based on the concept that CLL is a disease of progressive accumulation of nonfunctioning lymphocytes: stage O, bone marrow and blood lymphocytosis only; stage 1, lymphocytosis with enlarged nodes; stage II, lymphocytosis with enlarged spleen or liver or both; stage III, lymphocytosis with anemia; and stage IV:lymphocytosis with thrombocytopenia. Analysis of 125 patients. in the present series showed the following median survival times (in months) from diagnosis: stage 0, is greater than 150; stage I 101; stage II, 71; stage III, 19; stage IV, 19, The median survival for the entire series was 71 mo. The prognostic significance of the stage remained even after adjustment was made for age and sex. However, both sex and age were shown to be poor predictors of survival after adjustment for stage. The method of staging proved to be a reliable predictor of survival whether used at diagnosis or during the course of the disease. The proposed staging system was an equally accurate indicator for survival when applied to two other previously published studies of large series of patients.

International Staging System (ISS) Is Superior to Durie-Salmon (DS) Staging in Predicting Overall Mortality in Multiple Myeloma (MM)

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 2745-2745 ◽  
Author(s):  
Sikander Ailawadhi ◽  
Taimur Sher ◽  
Mehul Patel ◽  
Lyudmyla Derby ◽  
Terry Mashtare ◽  
...  
Keyword(s):  
Survival Data ◽  
Staging System ◽  
Stage I ◽  
Stage Iii ◽  
Disease Stage ◽  
Cell Transplant ◽  
Transplant Patients ◽  
Stage Disease ◽  
Staging Systems ◽  
International Staging System

Abstract Background: Despite recent therapeutic advancements, multiple myeloma (MM) remains an incurable disorder. Disease stage is the most commonly used parameter to determine tumor burden, need for treatment initiation and survival outcome. In this context the International Staging System (ISS) proposed in 2005 is considered a good predictor of overall survival (OS) and is reported to be more objective than the previous Durie-Salmon staging system (DSS). To date there has been no direct comparison to determine which of these is superior in predicting OS or mortality. Furthermore, ISS was defined prior to the routine availability of novel agents and primarily included MM patients who had undergone autologous stem cell transplant. Whether ISS has similar predictive value in non-transplant patients has not been reported. We investigated the ability to predict OS and mortality of these two staging systems in non-transplant patients with MM. Methods: All MM patients seen at RPCI between January 2004 and June 2007 were included in the analysis. Clinical staging was done as per the DSS and ISS in all patients. Descriptive baseline demographic data and survival data were collected. A 0.05 nominal significance level was used in all hypothesis testing. Results: A total of 170 consecutive patients were evaluated. None of the patients had undergone a stem cell transplant for their MM diagnosis. Survival data was available on 144 patients which are reported in this analysis. Of these 48% (n=69) were females and 52% (n=75) were males, with a median age of 60 years (range 35–83). The DSS revealed a distribution as follows: stage IA (21; 14.6%), stage IB (1; 0.7%), stage IIA (23; 16%), stage IIB (1; 0.7%), stage IIIA (81; 56.2%) and stage IIIB (17; 11.8%). The distribution as per ISS was stage I (76; 52.8%), stage II (31; 21.5%) and stage III (37; 25.7%). A Cox proportional hazards model was fit to compute a generalized R-square (Gen R2) statistic for the two staging systems and to compute hazard ratios (HR). The Gen R2 for DSS was 0.0259, while for ISS was 0.0461. Thus, by themselves, the two staging systems were not particularly predictive of OS. Comparison was then made by separating stage III (advanced stage disease) from stage I and II for both DSS and ISS. The estimated hazard of death for DSS I/II patients was not significantly different from the estimated hazard of death for DSS III patients (HR=0.48; 95% CI 0.2,1.14; p=0.09), while the estimated hazard of death for ISS I/II patients was significantly different from that for ISS III patients (HR=0.43; 95% CI 0.21,0.85; p=0.01). Exact odds ratios (OR) were computed between dichotomized DSS or ISS stage with patient status at years 1, 2 and 3 of follow up. Survival analysis at 1-year, 2-year and 3-year time point included 112, 93 and 77 patients, respectively. At 1-year, the sample odds of death for stage I/II patients were significantly different from the sample odds of death for stage III patients in both, the DSS (OR=0.32; 95% CI 0.1,0.93; p=0.02) and ISS (OR=0.25; 95% CI 0.08,0.25; p=0.005). At 2-year as well, this difference was significant for both, DSS (OR=0.32; 95% CI 0.1,0.98; p=0.03) and ISS (OR=0.18; 95% CI 0.06,0.63; p=0.002). At 3-year though, the DSS was no longer able to predict a significant difference in the sample odds of death between stage I/II and stage III patients (OR=0.4; 95% CI 0.11,1.34; p=0.11), while the sample odds of death as per the ISS were still significantly different (OR=0.21; 95% CI 0.04, 0.78; p=0.01). Conclusions: Our data from a prospective large cohort of non-transplant MM patients suggests that ISS is more predictive of overall mortality than the DSS. Furthermore, when comparing advanced stage disease (stage III) with early-stage disease (stage I/II), the DSS may only be able to predict short-term survival, while ISS is able to effectively predict survival over a prolonged period. Figure Figure

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