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Peter E Andersen

Publications and source records attributed to Peter E Andersen.

At least 19 recordsLinked to original sources
PubMed2006

The free NADH concentration is kept constant in plant mitochondria under different metabolic conditions.

The reduced coenzyme NADH plays a central role in mitochondrial respiratory metabolism. However, reports on the amount of free NADH in mitochondria are sparse and contradictory. We first determined the emission spectrum of NADH bound to proteins using isothermal titration calorimetry combined with fluorescence spectroscopy. The NADH content of actively respiring mitochondria (from potato tubers [Solanum tuberosum cv Bintje]) in different metabolic states was then measured by spectral decomposition analysis of fluorescence emission spectra. Most of the mitochondrial NADH is bound to proteins, and the amount is low in state 3 (substrate + ADP present) and high in state 2 (only substrate present) and state 4 (substrate + ATP). By contrast, the amount of free NADH is low but relatively constant, even increasing a little in state 3. Using modeling, we show that these results can be explained by a 2.5- to 3-fold weaker average binding of NADH to mitochondrial protein in state 3 compared with state 4. This indicates that there is a specific mechanism for free NADH homeostasis and that the concentration of free NADH in the mitochondrial matrix per se does not play a regulatory role in mitochondrial metabolism. These findings have far-reaching consequences for the interpretation of cellular metabolism.

Homeostasis↗
PubMed2006

Perioperative parathyroid hormone levels in thyroid surgery.

OBJECTIVE: Perioperative hypocalcemia from temporary parathyroid gland dysfunction is common after thyroid surgery. No reliable cutoff values for parathyroid hormone (PTH) and the subsequent possibility of developing hypocalcemia exist. The purpose of this study is to determine a criterion for predicting hypocalcemia based on different PTH levels as cutoff values. STUDY DESIGN: Retrospective chart review. METHODS: A centralized database of intraoperative PTH levels was analyzed. PTH values approximately 10 minutes after excision of the thyroid gland and in the recovery room were obtained; serial ionized calcium levels were also analyzed. PTH values were then compared using chi-square analysis with significance defined as P < .05. A receiver operator characteristic (ROC) curve was also constructed to define sensitivities and specificities of different PTH levels as potential cutoff values. RESULTS: Eighty patients were identified meeting the study criteria between January 1999 and February 2005. Fourteen of the 80 (17.5%) patients became hypocalcemic during the hospital stay; none experienced permanent hypocalcemia. Patients who became hypocalcemic during their hospitalization were more likely to have a PTH level below 15 pg/mL (P < .01). Patients with a PTH level less than 15 pg/mL were more likely to develop hypocalcemia (P < .01). Finally, an ROC curve was constructed, allowing the surgeon to determine acceptable sensitivities and specificities and various PTH cutoff values. CONCLUSION: Low perioperative PTH levels significantly correlate with the presence of postoperative hypocalcemia but cannot be used to predict it. Using the ROC curve allows different chosen cutoff values to predict hypocalcemia with varying sensitivity and specificity.

Biomarkers↗
PubMed2006

Modern management of laryngotracheal stenosis.

OBJECTIVES: Laryngotracheal stenosis is a complex problem resulting most often from intubation, trauma,or autoimmune disease. Management options include dilation or airway reconstruction including laryngotracheoplasty (LTP), cricotracheal resection (CTR), and tracheal resection (TR). We describe our experience with management of this difficult problem. STUDY DESIGN: Retrospective chart review of patients treated for laryngotracheal stenosis between January 1995 and July 2005 at an academic, tertiary referral center. METHODS: A total of 127 patients were treated during the study period. Patients were followed, and hospital records were reviewed. RESULTS: There were 38 male and 89 female patients with an average age of 55.5 years treated for laryngotracheal stenosis resulting from intubation (64), idiopathic (25) or autoimmune disease (18), radiation (9), trauma (5), prior surgery (4), and relapsing polychondritis (2). Thirty-three percent were treated for grade I stenosis, 44% grade II, 19% grade III, and 4% grade IV. Seventy percent of patients undergoing initial dilation required a subsequent procedure. LTP, CTR, or TR was performed in 43%, 48%, 71%, and 100% of patients with grade I through IV stenosis, respectively. Among 76 patients undergoing LTP, CTR, or TR, 24 (32%) required a subsequent intervention. Among 36 patients treated with primary LTP, CTR, or TR, only 10 (28%) required further therapy. Twenty-two of 35 (63%) tracheostomy-dependent patients were ultimately decannulated. Three patients died in the immediate postoperative period. CONCLUSIONS: Patients undergoing dilation for laryngotracheal stenosis require multiple procedures. However, major reconstructive procedures are well tolerated and currently represent a viable primary treatment for laryngotracheal stenosis.

Adult↗
PubMed2006

Anatomical analysis of transoral surgical approaches to the clivus.

OBJECT: The authors conducted a cadaveric anatomical study to quantify and compare the area of surgical exposure and the freedom available for instrument manipulation provided by the following four surgical approaches to the extracranial periclival region: simple transoral (STO), transoral with a palate split (TOPS), Le Fort I osteotomy (LFO), and median labioglossomandibulotomy (MLM). METHODS: Twelve unembalmed cadaveric heads with normal mouth opening capacity were serially dissected. For each approach, quantitation of extracranial periclival exposure and freedom for instrument manipulation (known here as surgical freedom) was accomplished by stereotactic localization. To quantify the extent of extracranial clival exposure obtained, anatomical measurements of the extracranial clivus were performed on 17 dry skull bases. The values (means +/- standard deviations in mm2) for periclival exposure and surgical freedom, respectively, for the surgical approaches studied were as follows: STO = 492 +/- 229 and 3164 +/- 1900; TOPS = 743 +/- 319 and 3478 +/- 2363; LFO = 689 +/- 248 and 2760 +/- 1922; and MLM 1312 +/- 384 and 8074 +/- 6451. The extent of linear midline clival exposure and the percentage of linear midline clival exposure relative to the total linear midline exposure were as follows, respectively: STO = 0.6 +/- 4.9 mm and 7.8 +/- 11%; TOPS = 8.9 +/- 5.5 mm and 24.2 +/- 16.7%; LFO = 32.9 +/- 10.2 mm and 85.0 +/- 18.7%; and MLM = 2.1 +/- 4.4 mm and 6.7 +/- 11.1%. CONCLUSIONS: The choice of approach and the resulting degree of complexity and associated morbidity depends on the location of the pathological entity. The authors found that the MLM approach, like the STO approach, provided good exposure of the craniocervical junction but limited exposure of the clivus. The TOPS approach, an approach attended by a lesser risk of morbidity, provided adequate exposure of the extracranial inferior clivus. Maximal exposure of the extracranial clivus proper was provided by the LFO approach.

Cranial Fossa, Posterior↗
PubMed2005

Competing simple cleavage reactions: the elimination of alkyl radicals from amine radical cations.

Two different alkyl radicals can be expelled when unsymmetrical aliphatic amine radical cations undergo C-C bond cleavage. The branching ratio is strongly dependent on the internal energy of the reactant, even when the competition involves loss of closely related alkyl radicals. In mass spectrometers, the rate of loss of the smaller radical (excepting methyl) always exceeds the rate of loss of the larger close to threshold. The preference is reversed for the more highly energized ions that react in the ion source, demonstrating that the rate of loss of the larger radical rises much more rapidly with increasing internal energy than does the rate of loss of the smaller radical. This result is not easily reconciled with a simple RRKM model, given the expected strong resemblance between the transition states involved, whereas it agrees well with a description based on variational transition state theory. The heats of formation of the products determined with the G3 composite ab initio method show that loss of the smaller radical is without exception the more favorable reaction. The relative rates of the competing C-C bond cleavage reactions of the metastable ions vary with the number of degrees of freedom of the reactant, with the critical energy of the reaction, and with the difference between the heats of formation of the products. The presence of intermediate energy barriers when cleavage occurs at a branching point can give rise to variations in relative rates that are not easily interpreted.

Journal Article↗
PubMed2004

Extraction of optical scattering parameters and attenuation compensation in optical coherence tomography images of multilayered tissue structures.

A recently developed analytical optical coherence tomography (OCT) model [Thrane et al., J. Opt. Soc. Am. A 17, 484 (2000)] allows the extraction of optical scattering parameters from OCT images, thereby permitting attenuation compensation in those images. By expanding this theoretical model, we have developed a new method for extracting optical scattering parameters from multilayered tissue structures in vivo. To verify this, we used a Monte Carlo (MC) OCT model as a numerical phantom to simulate the OCT signal for heterogeneous multilayered tissue. Excellent agreement between the extracted values of the optical scattering properties of the different layers and the corresponding input reference values of the MC simulation was obtained, which demonstrates the feasibility of the method for in vivo applications. This is to our knowledge the first time such verification has been obtained, and the results hold promise for expanding the functional imaging capabilities of OCT.

Algorithms↗
PubMed2004

Advanced modelling of optical coherence tomography systems.

Analytical and numerical models for describing and understanding the light propagation in samples imaged by optical coherence tomography (OCT) systems are presented. An analytical model for calculating the OCT signal based on the extended Huygens-Fresnel principle valid both for the single and multiple scattering regimes is reviewed. An advanced Monte Carlo model for calculating the OCT signal is also reviewed, and the validity of this model is shown through a mathematical proof based on the extended Huygens-Fresnel principle. Moreover, for the first time the model is verified experimentally. From the analytical model, an algorithm for enhancing OCT images is developed: the so-called true-reflection algorithm in which the OCT signal may be corrected for the attenuation caused by scattering. For the first time, the algorithm is demonstrated by using the Monte Carlo model as a numerical tissue phantom. Such algorithm holds promise for improving OCT imagery and to extend the possibility for functional imaging.

Algorithms↗
PubMed2004

Impact of retropharyngeal lymph node metastasis in head and neck squamous cell carcinoma.

BACKGROUND: The impact of metastasis to the retropharyngeal lymph node (RPLN) group is poorly understood because of the difficult access of the retropharyngeal space. Previous studies concluding to the negative impact of RPLN metastasis rely heavily on radiographic assessment, which introduces the possibility of diagnostic error. OBJECTIVE: To better define the prognostic significance of metastatic retropharyngeal adenopathy in patients with non-nasopharyngeal squamous cell carcinoma of the head and neck. STUDY DESIGN: A retrospective cohort study of patients with non-nasopharyngeal squamous cell carcinoma of the head and neck who underwent resection of the RPLN group and were followed up for an average of 24 months. SETTING: Tertiary care academic medical center. PATIENTS: The 51 patients included in the study had been treated for advanced-stage squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, and/or supraglottic larynx via a surgical approach to the primary tumor that afforded access to the RPLN group. All patients underwent dissection and pathologic interpretation of the RPLNs, most patients received postoperative radiotherapy, and 43 patients met survival analysis criteria. MAIN OUTCOME MEASURES: Local and regional recurrence rates, the development of distant metastasis, and disease-free and overall survival. RESULTS: Metastasis to the RPLN group was confirmed pathologically in 14 (27.5%) patients. There was no statistically significant difference between patients with and without RPLN metastasis in rates of local recurrence (24.8% vs 28.4%), regional recurrence (17.5% vs 19.6%), distant metastasis (17.0% vs 11.2%), disease-free survival (40.5% vs 30.5%), and overall survival (40.6% vs 38.5%). CONCLUSION: Metastasis to the RPLN group does not impact disease control or survival in patients with advanced non-nasopharyngeal squamous cell carcinoma of the head and neck treated with multimodality therapy.

Adult↗
PubMed2004

Polymorphisms of GSTT1 and related genes in head and neck cancer risk.

BACKGROUND: Glutathione S-transferase T1 detoxifies some environmental carcinogens while activating others and is deleted in 15% to 38% of humans. We sought to determine whether GSTT1 genotype and genotypes of several related genes are associated with risk of squamous cell carcinoma of the head and neck (HNSCC). METHODS: Somatic genotypes for GSTT1, GSTM1, GSTP1, and CYP1A1 were determined in 283 individuals with HNSCC and 208 population-based controls. RESULTS: The OR for presence of GSTT1 was 1.6 (CI, 1.1-2.5, p = 0.03). HNSCC risk was not associated with GSTM1 null genotype, the presence of the GSTP1 Val/Val genotype, or the Val/Val homozygous genotype for CYP1A1. Stratified analysis revealed disparate ORs for women (OR, 3.0; CI, 1.5-6.3) and men (OR, 1.2; CI, 0.7-2.1) for the presence of GSTT1. CONCLUSIONS: In this population, the presence of GSTT1 gene was associated with a significant increase in the risk of HNSCC. This association was particularly robust in women.

Aged↗
PubMed2004

Outpatient endoscopic Zenker diverticulotomy.

OBJECTIVES/HYPOTHESIS: Staple-assisted, endoscopic Zenker diverticulotomy has been shown to decrease both cost of treatment and length of convalescence when compared with the standard open approach. Although the endoscopic technique is generally considered to be safe, the feasibility of outpatient endoscopic Zenker diverticulotomy has never been reported. STUDY DESIGN: Retrospective cohort study. METHODS: All endoscopic Zenker diverticulotomy procedures performed at Oregon Health and Science University (Portland, OR) between 1998 and 2002 were reviewed. The study group was limited to patients whose surgeries were planned on an outpatient basis. Medical charts were reviewed for indications, demographics, operative findings, complications, and resolution of symptoms. RESULTS: Of the 51 patients who underwent endoscopic, staple-assisted Zenker diverticulotomy, 40 were treated with the intent of outpatient management. Thirty-two cases were primary surgeries, and eight cases were revision treatments. The average patient age was 68 years (age range, 35-91 y), and the mean follow-up period was 5.9 months (range, 1-37 mo). Eight (20%) complications were noted in the study group. Intraoperative complications included 3 patients (7.5%) with mucosal disruptions. These patients underwent uneventful suture repair of small hypopharyngeal mucosal tears encountered intraoperatively and were temporarily observed in the hospital. One patient was admitted for postoperative urinary retention and another for fever and tachycardia 48 hours after surgery. One patient sustained a myocardial infarction. The remainder of patients were fed immediately and discharged home on the day of surgery. Two patients (5%) had iatrogenic tooth fracture. CONCLUSION: Appropriately selected patients undergoing endoscopic, staple-assisted Zenker diverticulotomy can be managed safely on an outpatient basis. Intraoperative complications, such as a mucosal disruption, warrant conversion to inpatient monitoring.

Adult↗
PubMed2004

Perioperative parathyroid hormone levels in thyroid surgery: preliminary report.

OBJECTIVES/HYPOTHESIS: An immediate method of accurately predicting postoperative hypocalcemia after total thyroidectomy would allow for selective early discharge of patients at low risk. The objective of the study was to determine the utility of perioperative parathyroid hormone measurement in predicting postoperative hypocalcemia after a thyroid surgery that places total parathyroid function at risk. STUDY DESIGN: Prospective case series. METHODS: Twenty-seven patients undergoing total or completion thyroidectomy had three blood samples drawn for parathyroid hormone measurement before dissection, 10 minutes after specimen removal, and in the recovery room. Serial ionized calcium levels were measured in the postoperative period. Preoperative, postresection, and recovery room levels were compared with postoperative ionized calcium levels. RESULTS: The average values before resection, after resection, and in the recovery room were 69.3 (range, 13-163), 42.3 (range, 0-120), and 37.4 (range 7-79) pg/mL, respectively. The incidence of hypocalcemia was 11% (3 of 27 patients). The rate of hypocalcemia was significantly higher (50%) in patients with recovery room parathyroid hormone values of 10 pg/mL or less relative to patients with recovery room parathyroid hormone values greater than 10 pg/mL (4%) in this setting (P =.01). Among patients with a parathyroid hormone value of less than 15 pg/mL in the recovery room, an increasing parathyroid hormone level in the recovery room relative to the level after resection predicted normocalcemia without calcium supplementation on chi analysis (P =.01). CONCLUSION: The study demonstrated that perioperative parathyroid hormone values can help predict patients who are at highest risk for postoperative hypocalcemia after thyroid surgery.

Calcium↗
PubMed2003

Absolute refractive index determination by microinterferometric backscatter detection.

Microinterferometric backscatter detection (MIBD) has previously been shown capable of measuring changes in the refractive index of liquids on the order of 10(-7). The MIBD technique is based on interference of laser light after it is reflected from different regions in a capillary. These reflections generate an interference pattern that moves upon changing refractive index of the liquid in the capillary. The small-angle interference pattern traditionally considered has a repetition frequency in the refractive index space that limits the ability to measure refractive index-to-refractive index changes causing such a repetition. Such refractive index changes are typically on the order of three decades. Recent modeling and experiments with the MIBD technique have shown that other intensity variations in the pattern are present for larger backscattered angles. By considering these variations, we have shown two methods by which it is possible to extend the dynamic measurement range to make an absolute refractive index measurement. One method utilizes variations in the Fresnel coefficients while the second approach is based on the refractive index-dependent onset of total internal reflection angles. With the second approach, we have been able to measure the absolute refractive index of a liquid with a precision of 2.5 x 10(-4).

Journal Article↗
PubMed2003

Cricopharyngeal spasm and Zenker's diverticulum.

Cricopharyngeal spasm and Zenker's diverticulum represent disorders of the pharyngoesophageal junction for which a unifying theory of etiology has yet to be established. There is, however, a large body of evidence that supports an association with gastroesophageal reflux. Cricopharyngeal myotomy is the key to successful management of both disorders. Newer transoral endoscopic techniques of management have a lower overall morbidity than traditional open approaches in appropriately selected patients and are therefore gaining popularity as the preferred method of treatment.

Algorithms↗
PubMed2003

An analysis of time and staff utilization for open versus percutaneous tracheostomies.

OBJECTIVE: We examined staff utilization and procedure length for percutaneous and open bedside tracheostomies in an intensive care setting. STUDY DESIGN: Prospective clinical outcomes study. METHODS: Intensive care unit (ICU) tracheostomy consults meeting criteria for bedside procedures were randomized to open or percutaneous procedures. The Cook percutaneous kit and a prepackaged tracheostomy tray were used. ICU nursing and respiratory therapy staff was present for all procedures. The total resident time, staff time, and procedure length were recorded. Twelve patients underwent percutaneous tracheostomy, and 12 received an open tracheostomy. RESULTS: An operating room nurse was present for 7 of the open procedures. Ancillary medical staff was present for 3 open tracheostomies: anesthesia for 2 and critical care for 1. Ancillary medical staff was present for 4 percutaneous tracheostomies: anesthesia staff for 1 and critical care for 3. The average resident presence, staff presence, and procedure length for open tracheostomies were 47, 30, and 12 minutes, respectively. For percutaneous tracheostomies, the times were 39, 29, and 12 minutes, respectively. One intraoperative complication occurred during a percutaneous procedure and 2 perioperative complications occurred: 1 in the open group and 1 in the percutaneous group. CONCLUSIONS: There was no significant difference in procedure length, resident time, or staff time between the 2 procedures. Ancillary staff was occasionally used but was not thought to be necessary for the majority of procedures. Both procedures can be safely and expediently performed in the ICU.

Adult↗
PubMed2003

Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery.

OBJECTIVES/HYPOTHESIS: The incidence of cerebrospinal fluid (CSF) leak following trans-sphenoidal surgery ranges from 0.5% to 15.0%. Factors predicting which patients are likely to develop postoperative leaks and optimal management of these patients are poorly defined. The objective was to determine 1) the incidence of CSF leak following trans-sphenoidal surgery; 2) demographic or intraoperative factors associated with postoperative leaks; 3) techniques and efficacy of postoperative leak management at Oregon Health and Science University, (Portland, OR). STUDY DESIGN: Retrospective chart review. METHODS: Two hundred thirty-five trans-sphenoidal surgeries were performed on 216 patients between 1994 and 2001. Follow-up data were available for 217 operations (92.3%) performed on 202 patients (93.5%). RESULTS: Postoperative CSF leaks occurred in 6.0% (13 of 217) of patients. Leaks were more common in the setting of revision surgery versus primary surgery (14.6% vs. 4.0%, P =.0096), nonadenomatous disease versus pituitary adenoma (15.8% vs. 5.1%, P =.059), or if an intraoperative leak occurred (12.7% vs. 2.7%, P =.004). However, on multivariate analysis, only the presence of intraoperative leak (P =.008) and nonadenomatous disease (P =.047) were found to be independently associated with postoperative CSF leak. Size of adenoma was not associated with occurrence of postoperative CSF leak (6.4% for microadenoma vs. 4.2% for macroadenoma) on both univariate and multivariate analysis. There were 13 postoperative CSF leaks: 2 resolved with lumbar drainage and 11 required operative management (three required multiple procedures). Of the three patients who required multiple operations, two had hospital courses complicated by meningitis and postinfectious hydrocephalus and ultimately required ventriculoperitoneal shunts. Endoscopic re-exploration was successful in 87.5% (7 of 8) of cases. CONCLUSIONS: Cerebrospinal fluid leaks following trans-sphenoidal surgery occurred in 6.0% of cases. Nonadenomatous disease and presence of an intraoperative leak were independent predictors of a postoperative leak. Endoscopic re-exploration combined with packing was an effective technique in managing uncomplicated postoperative leaks. In the setting of meningitis and postinfectious hydrocephalus, more invasive techniques such as ventriculoperitoneal shunt may be necessary.

Cerebrospinal Fluid↗
PubMed2003

Swallowing function and tracheotomy dependence after combined-modality treatment including free tissue transfer for advanced-stage oropharyngeal cancer.

OBJECTIVES/HYPOTHESIS: There are many treatments available for advanced oropharyngeal cancer. Organ-sparing protocols reserve surgery for salvage and are thought to provide adequate rehabilitation. Surgical resection with free tissue transfer may also provide adequate functional rehabilitation. The objective was to describe swallowing status and time to decannulation in a series of patients treated with combined-modality therapy that included free flap reconstruction. STUDY DESIGN: Retrospective chart review. METHODS: Patient data were obtained from medical records of 20 patients with stage III or IV oropharyngeal carcinoma, who were consecutively treated with surgical tumor extirpation, free flap reconstruction, and postoperative irradiation at a tertiary academic center from 1985 to 2002. The following variables were identified: patient and tumor characteristics, free flap type, irradiation data, and airway and swallowing status before and after treatment. RESULTS: One patient underwent total laryngopharyngectomy, and the remaining 19 patients underwent tracheotomy at the time of definitive surgery. Free flap reconstructions included 1 ulnar and 15 radial forearm fasciocutaneous flaps and 4 fibula osteocutaneous flaps. Postoperatively, all 19 tracheotomized patients had successful decannulation. Average time to decannulation was 15 days (range, 3-42 d). After surgery and before irradiation, 13 patients initiated oral intake, on average, at 19.5 days (range, 7-28 d); 6 patients required no additional supplementation. By 4 months after surgery, having completed radiation therapy, 10 patients were consuming all nutrition orally; the other 10 patients still required tube-feed supplementation, although 6 of these patients were also eating by mouth. CONCLUSION: Combined-modality treatment that includes free flap reconstruction for advanced-stage oropharyngeal cancer may provide reasonable functional rehabilitation with respect to postoperative airway and swallowing.

Aged↗
PubMed2003

Short-term functional donor site morbidity after radial forearm fasciocutaneous free flap harvest.

OBJECTIVES/HYPOTHESIS: The existing literature on postoperative donor extremity function describes a spectrum of morbidity in the long term (>3 mo after surgery). However, the consensus is that there is minimal to no impact of flap harvest on patients' activities of daily living. No previous reports have examined functional donor site morbidity in the early postoperative period; such may affect patients' overall perioperative progress, especially with respect to donor extremity dominance. The authors' objective was to quantify functional morbidity of the donor site in radial forearm fasciocutaneous free flaps during the early postoperative period. STUDY DESIGN: Retrospective case series review. METHODS: Patient data were obtained from hospital records of 12 consecutive patients who underwent head and neck reconstruction with radial forearm fasciocutaneous free tissue transfer over a 6-month period at a tertiary academic medical center. Functional results of each patient's donor extremity obtained preoperatively and at 5 to 8 days after surgery were determined by quantifying forearm supination and pronation, wrist flexion and extension, and sharp and dull hand sensations in radial, median, and ulnar nerve distributions. RESULTS: Mean patient age was 57 years (age range, 42-71 y). The nondominant extremity was the donor site in 9 of 12 patients. Using the paired two-tailed t test, statistically significant differences were demonstrated in preoperative versus postoperative forearm supination (P <.032), pronation (P <.006), wrist flexion (P <.000), and wrist extension (P <.000). Three of 12 patients demonstrated diminished sharp sensation in the "anatomical snuffbox" distribution. CONCLUSION: The authors describe statistically significant functional forearm and wrist range-of-motion morbidity associated with the harvest of a radial forearm fasciocutaneous free flap in the early postoperative period.

Activities of Daily Living↗