Journal Pre-proof

Nerve compression injuries after prolonged prone position ventilation in SARS-CoV-2

patient: a case series.

Luigia Brugliera, M.D. Ph.D, Massimo Filippi, M.D., Ubaldo Del Carro, M.D, Calogera
Butera, M.D, Francesca Bianchi, M.D, Paola Castellazzi, M.D, Paolo Cimino, M.D,
Paolo Capodaglio, M.D, Giacomo Monti, M.D, Pietro Mortini, M.D, Luca G. Pradotto,
M.D, Lorenzo Priano, M.D, Alfio Spina, M.D., Sandro Iannaccone, M.D

PII: S0003-9993(20)31252-1
DOI: https://doi.org/10.1016/j.apmr.2020.10.131
Reference: YAPMR 58040

To appear in: ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 17 July 2020

Revised Date: 18 October 2020
Accepted Date: 23 October 2020

Please cite this article as: Brugliera L, Filippi M, Del Carro U, Butera C, Bianchi F, Castellazzi P, Cimino
P, Capodaglio P, Monti G, Mortini P, Pradotto LG, Priano L, Spina A, Iannaccone S, Nerve compression
injuries after prolonged prone position ventilation in SARS-CoV-2 patient: a case series., ARCHIVES OF
PHYSICAL MEDICINE AND REHABILITATION (2020), doi: https://doi.org/10.1016/j.apmr.2020.10.131.

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© 2020 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine
Nerve compression injuries after prolonged prone position ventilation in SARS-

CoV-2 patient: a case series.

Luigia Brugliera1 M.D. Ph.D, Massimo Filippi2 M.D., Ubaldo Del Carro3, M.D.,

Calogera Butera3, M.D., Francesca Bianchi3, M.D., Paola Castellazzi1, M.D., Paolo

Cimino1, M.D., Paolo Capodaglio4, M.D., Giacomo Monti5, M.D., Pietro Mortini6,

M.D., Luca G. Pradotto7,8, M.D., Lorenzo Priano7,8, M.D., Alfio Spina6 M.D., Sandro

Iannaccone1, M.D.

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1
Department of Rehabilitation and Functional Recovery, I.R.C.C.S. San Raffaele

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Scientific Institute, Vita-Salute University, Milan, Italy

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Neuroimaging Research Unit, Institute of Experimental Neurology, Division of
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Neuroscience, Neurology Unit, Neurophysiology Unit, I.R.C.C.S. San Raffaele
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Scientific Institute, Milan, Italy/Vita-Salute San Raffaele University, Milan, Italy

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Neurophysiology Unit, I.R.C.C.S. San Raffaele Scientific Institute, Milan, Italy
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Rehabilitation Unit, I.R.C.C.S. Istituto Auxologico Italiano, Piancavallo, Italy
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5
Department of Anaesthesia and Intensive Care, I.R.C.C.S. San Raffaele Scientific

Institute, Vita-Salute University, Milan, Italy

6
Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San

Raffaele Scientific Institute, Vita-Salute University, Milan, Italy

7
Neurology Unit, I.R.C.C.S. Istituto Auxologico Italiano, Piancavallo, Italy

8
Department of Neuroscience, University of Torino, Turin, Italy
Running head: Nerve injuries after prone position ventilation in SARS-CoV-2

COMPLIANCE WITH ETHICAL STANDARDS

Conflict of interest

The authors declare no competing financial interests.

Funding

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No funding was received for this research.

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Ethical approval
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Procedures were approved by the Ethics Committee and followed the ethical
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standards laid down in the 1964 declaration of Helsinki.
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Informed consent

All participants were informed about the study and gave a written informed consent.
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Corresponding Author

Luigia Brugliera, M.D. Ph.D.

Department of Rehabilitation and Functional Recovery,

I.R.C.C.S. San Raffaele Scientific Institute

Vita-Salute University

Via Olgettina 60, 20132, Milan, Italy

Phone: +39 3921043654

Mail: brugliera.luigia@hsr.it

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 1 ABSTRACT

2 Background. Prone positioning improves oxygenation in adult respiratory distress syndrome. This

3 procedure has been widely used during the SARS-CoV-2 pandemic. However, this procedure can

4 also be responsible for nerve damage and plexopathy.

5 Methods. We retrospectively reviewed a series of 7 infectious COVID-19 patients who underwent

6 prone positioning ventilation at the San Raffaele Hospital of Milan (Italy), during the SARS-CoV-2

7 pandemic.

8 Results. Clinical and neurophysiological data of 7 patients suffering from nerve compression

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9 injuries have been reported.

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10 Conclusions. Healthcare workers should take into consideration the risk factors for prone

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positioning-related plexopathy and nerve damage, especially in COVID-19 patients, to prevent this
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12 type of complication.
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13
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14 Keywords: SARS-CoV-2; COVID-19; Prone positioning; Nerve Damage; Plexopathy; Brachial

15 plexus
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17 Abbreviations

18 ADM: Abductor digiti minimi

19 ARDS: Adult respiratory distress syndrome

20 BB: Biceps brachii

21 BMI: Body mass index

22 BR: Brachioradialis

23 CMAP: Compound muscle action potential

24 COVID-19: Covornavirus disease 2019

25 EMG: Electromyography

26 ENG: Electroneurography

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27 FCR: Flexor carpi radialis

28 FDI: First dorsal interosseous

29 GMED: Gluteus medius

30 ICU: Intensive Care Units

31 IS: Infraspinatus

32 MUAPs: Motor unit action potentials

33 MUST: Malnutrition Universal Screening Tool

34 NIV: Non-invasive ventilation

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35 PL: Peroneus longus

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36 PP: Prone position

37 SAP: Sensory nerve action potential -p

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38 SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2
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39 SPE: Sciatic popliteus externus

40 SS: Supraspinatus
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41 TA: Tibialis anterior

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42 TB: Triceps brachii

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43

44

45

46

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47 INTRODUCTION

48 Prone positioning (PP) has been used since the ‘70s to improve oxygenation in adult respiratory

49 distress syndrome (ARDS) and has been intensively applied in Intensive Care Units (ICU) during

50 the SARS-CoV-2 pandemic.[1] It has been estimated that about 5% of SARS-CoV-2 patients with

51 ARDS would require mechanical ventilation.[2-4] A recent editorial published in JAMA about PP

52 stated that “tolerance is sometimes a limitation of the technique, the physiological effects are not

53 clarified, and the benefits of very short sessions may be questionable”.[4] In March 2020, in

54 response to the dramatic number of patients simultaneously requiring ICU admission in north-

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55 western Europe, Italian hospitals created new units, specifically dedicated to the treatment of

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56 SARS-CoV-2 critical patients.[5-7] This extraordinarily high need for intensive care during the

57
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pandemic peak generated a series of health management issues. Several ICU workers, not routinely
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58 devoted to ARDS management, were not familiar with PP procedures. The total amount of hours
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59 spent in the prone position per cycle (16 hours per day) could therefore show high inter-individual
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60 variability. Because of the overload of patients’ admissions and the increased need for lung

61 ventilation, some patients did not undergo several PP cycles per day, as required, whereas other
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62 patients benefited from extended pronation protocols, sometimes outlasting 16 hours per day.
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63 Prolonged static position on intensive care beds increases patient’s exposure to localized

64 compression in specific body areas. In the particular case of PP associated with ARDS-related

65 mechanical ventilation, complications due to prolonged exposure have been previously

66 described.[8,9] According to the guidelines of the German Society of Anaesthesiology and

67 Intensive Care Medicine, nerve compression injury after prolonged PP is a very rare condition

68 (evidence level 2b).[10] However, the same authors commented that the incidence of PP-related

69 complications had not been sufficiently studied and that further investigations were needed.[10] To

70 present further evidence of PP-related complications, we retrospectively collected data from 7

71 critically ill patients diagnosed with SARS-CoV-2 that were intubated and mechanically ventilated

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72 in a prone position for a prolonged time at the ICU of the San Raffaele Hospital (Milan, Italy) and

73 consecutively transferred to the Rehabilitation Unit of the same hospital.[5]

74 CASE SERIES

75 Case #1: Bilateral axillary, suprascapular nerves’ lesion, and bilateral mono-neuropathy of

76 ulnar nerve proximal to the elbow.

77 A 40-year-old man diagnosed with SARS-Cov-2 pneumonia received mechanical ventilation for 19

78 days. Initially, non-invasive ventilation (NIV) was applied for 2 days. After the worsening of his

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79 respiratory failure, the patient was intubated and IV in PP was applied for 17 days. After pulmonary

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80 distress resolution, the patient complained of proximal hyposthenia of both upper limbs and

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paraesthesia of the hands. Electromyography (EMG) revealed acute denervation (i.e. fibrillation

potentials) of bilateral deltoids, supraspinatus and infraspinatus muscles, abductor digiti minimi and
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83 flexor ulnaris carpis. No further denervation was observed in the remaining upper limb muscles or
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84 the cervical paraspinal or serratus anterior muscles. Electroneurography (ENG) evidenced a

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85 reduction of ulnar sensory action potential (SAP) amplitude without focal motor conduction
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86 slowing. The patient was thus diagnosed with bilateral axillar and suprascapular axonal damage
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87 associated with bilateral mono-neuropathy of the ulnar nerve, proximal to the elbow.

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89 Case #2: Bilateral ulnar nerve neurapraxia at the elbow level.

90 A 55-year-old man suffering from SARS-Cov2 pneumonia underwent IV in PP for 7 days. After

91 ceasing sedation, the patient presented with bilateral hypoesthesia of the fifth fingers. No risk

92 factors for compressive neuropathy were identified, apart from the presence of a hematoma in the

93 left deltoid muscle, apparently unrelated to the clinical findings. Nerve conduction measurements

94 showed a bilateral slowing of motor and sensory ulnar nerve velocity around the elbow (in the

95 segment from above to below the elbow). Needle EMG revealed a moderately decreased

96 recruitment pattern in the first dorsal interosseous muscle, bilaterally. Positive sharp waves, or

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 97 fibrillation potentials, were absent. These findings supported the diagnosis of focal neurapraxia of

98 both ulnar nerves at the elbow level.

99

100 Case #3: Axonotmesis of the left ulnar nerve.

101 A 47-year-old man diagnosed with SARS-Cov2 pneumonia underwent IV in PP for 19 days. While

102 undergoing IV, the patient suffered from a septic state. After regaining consciousness, the patient

103 suffered from hyposthenia and hypoesthesia of his left upper limb. Compound muscle action

104 potential (CMAP) could not be recorded from abductor digiti minimi (ADM) and first dorsal

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105 interosseous (FDI) muscles, both with distal and proximal sites of stimulation. Distal SAPs of the

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106 left ulnar nerve were also absent. Conduction studies of the left axillary, left radial, right ulnar, right

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and left median nerves, together with F-wave evoked by left median nerve stimulation were within
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108 the normal ranges. Needle examination in ADM, FCU, and FDI muscles showed fibrillations during
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109 the resting phase, and no motor unit action potentials during the recruitment phase. Overall, these
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110 findings indicated a complete axonal lesion of the left ulnar nerve at the elbow level, or proximally.

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112 Case #4: Left brachial plexopathy (upper trunk).

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113 A 51-year-old man suffering from non-insulin-dependent diabetes mellitus was diagnosed with

114 SARS-Cov2 and developed pneumonia. The patient received hydroxychloroquine 400 mg, lopinavir

115 400 mg, and ritonavir 100 mg per day. Due to a worsening of his respiratory function, mechanical

116 ventilation (NIV for 6 days and IV for 8 days) was performed in PP for 14 days. After ceasing

117 sedation, the patient presented with hyposthenia of the left upper limb. Motor and sensory nerve

118 conduction studies of the median and ulnar nerves, motor conduction study of the left axillary

119 nerve, and F-wave evoked by the stimulation of the left median and ulnar nerves were within

120 normal ranges, bilaterally. Needle examination of the left supraspinatus (SS), infraspinatus (IS),

121 deltoid, biceps brachii (BB) and brachioradialis (BR) muscles showed active denervation during the

122 resting phase and moderate reduction of motor unit action potentials’ (MUAPs) recruitment during

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123 maximal contraction. No denervation of cervical paraspinal muscles and left serratus anterior

124 muscles was observed. Overall, these findings indicated acute partial axonal damage of the upper

125 trunk of the left brachial plexus.

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127 Case #5: Right brachial plexopathy (rostral portion), possible overlap with right

128 musculocutaneous nerve injury; left lumbosacral plexopathy.

129 A 61-year-old man complained about hyposthenia of his right upper limb and left lower limb after

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130 discharge from ICU. The patient had been diagnosed with SARS-Cov-2 pneumonia and received

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131 NIV for 22 days, 9 of which in PP. A hematoma in the anterior compartment of the right arm was

132 observed.
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133 Neurophysiological measurements showed a complex clinical picture. ENG evidenced normal
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134 conduction parameters, except for focal entrapment of the right ulnar nerve at the elbow and right
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135 median nerve at the wrist. There were also reductions of CMAP amplitude over the left sciatic

136 popliteus externus (SPE) nerve and SAP over the left sural nerve. EMG showed a reduction of
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137 spatial recruitment of the right BR, flexor carpi radialis (FCR) and triceps brachii (TB) with
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138 complete denervation of BB. In the lower limbs, EMG evidenced almost complete denervation (i.e.

139 acute denervation and no voluntary activity) of left tibialis anterior (TA), left gluteus medius

140 (GMED), and left peroneus longus (PL) muscles. No spontaneous activity was evidenced in lumbar

141 paraspinal muscles.

142 These findings suggested a marked axonal lesion of the left lumbosacral plexus and a mild

143 neurapraxic lesion of the right brachial plexus (upper and medium trunks), with overlying complete

144 damage of the right musculocutaneous nerve (probably due to upper limb hematoma).

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146 Case #6: Neuroapraxia of the right ulnar nerve at elbow level and moderate impairment of

147 the right median nerve at the wrist; axonotmesis of the right peroneal nerve at the popliteal

148 fossa/fibular head.

149 A 76-year-old man suffering from non-insulin-dependent diabetes mellitus and chronic renal failure

150 developed SARS-CoV-2 pneumonia. The patient had been treated with mechanical ventilation for

151 37 days (NIV for 21 days and IV for 16 days) and had been prone-positioned for a total of 16 days.

152 After regaining consciousness, the patient presented with right upper and lower limbs hyposthenia.

153 The neurophysiological investigations revealed a moderate focal entrapment of the right ulnar nerve

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154 at the elbow and the right median nerve at the wrist, while, at the lower limb, an almost complete

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155 focal axonal lesion of the right SPE nerve was observed over the fibular head.

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157 Case #7: Focal right ulnar nerve impairment at the elbow.
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158 A 43-year-old man, diagnosed with SARS-Cov2 pneumonia, underwent IV in PP for 13 days. After
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159 regaining consciousness, the patient complained about hyposthenia of his right hand and

160 hypoesthesia of the ulnar side and fifth finger of his right hand. The neurological examination
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161 showed a moderate hyposthenia and hypotrophy involving the interosseous, the ulnar lumbrical and
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162 the hypothenar muscles of his right hand. A deficit of the adductor pollicis muscle was also

163 observed with the “signe de journal”, thus suggesting a right ulnar injury. Nerve conduction study

164 showed focal entrapment of the right ulnar nerve at the elbow. Needle electromyography revealed,

165 in the right FDI, moderately decreased recruitment patterns and fibrillations during the resting

166 phase. These findings suggested the presence of a right ulnar nerve axonal and neurapraxic

167 impairment at the elbow level.

168

169 DISCUSSION

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170 Positions that appear to cause brachial plexopathy include upper limb abduction with external

171 rotation and posterior shoulder displacement for periods as short as 45 minutes.[8,10] General

172 anesthesia and mal-positioning increase the risk of nerve injury because of the loss of normal

173 muscle tone as well as the patient’s inability to report discomfort. The prevalence of nerve injuries

174 due to operative positioning was estimated at around 0.14%. Most cases (38%) consisted of brachial

175 plexopathies following sternotomy.[8] Recovery occurred typically within 6 months in 92% of

176 patients.[8] Prolonged immobilization in intensive beds can increase the risk of skin pressure

177 necrosis and localized nerve compression. So far, in the largest study of PP, Gattinoni et al. found

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178 complications related to skin pressure in 36% of patients.[8] In 2002, Goettler et al. reported

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179 brachial plexopathy in 2 ARDS patients after prolonged PP in ICU.[3] Turning the patient’s head to

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the opposite side has been suggested to increase the stretch, but this was not confirmed by a
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181 cadaveric study.[8] Compression neuropathies after IV with PP have been so far considered as rare
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182 conditions.[10,3] However, in the 2 months of SARS-CoV-2 peak pandemic in northern Italy, 7
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183 cases of compression injuries out of 135 patients who had undergone IV in PP have been observed.

184 All of the 7 patients were male. Prevalence of the condition among SARS-CoV-2 patients
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185 discharged from ICU was therefore about 5%. Several factors may have accounted for such
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186 complications. It is known that males are more likely to develop compression neuropathies than

187 females.[11] Moreover, males would need high-levels and longer-lasting IV than females patients in

188 ICU.[11] Genetic and metabolic factors, in particular obesity and diabetes, may also have facilitated

189 the occurrence of this complication. Abnormal anatomy may also contribute to the risk of

190 neuropathy. Four out of the 7 patients presented one risk factor and 1 patient had two risk factors

191 (Table 1). We can thus conclude that extra care during prolonged PP procedures must be applied in

192 patients presenting with one or more risk factors for nerve injury. SARS-CoV-2 infection in

193 combination with IV in PP seems to increase the risk of developing compression nerve injuries. PP

194 procedures require expert skills. Extra care must be taken with arm positioning and motion while

195 patients are prone. The positioning of the chest roll and the type of surface the patient is placed on

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196 must be evaluated to ensure that the shoulders are not posteriorly extended. Proper positioning and

197 rolling technique may decrease the risk of brachial plexopathy. Therefore, a well-trained healthcare

198 team is mandatory to perform such procedures. This has certainly represented a critical issue during

199 the recent pandemic.

200 The important weight loss in our patients may also have played a role as a potential contributing

201 factor.[12] All patients reported a low body mass index (BMI) and risks of malnutrition, according

202 to the Malnutrition Universal Screening Tool (MUST) score. Such factors can increase risk for

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203 nervous system damages.[13] Indeed, excessive weight loss leads to the decrease of the fatty

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204 cushion protecting the nerve, which can predispose to a mechanical nerve injury.[12] Furthermore,

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altered nutritional status can increase the probability of nerve damage or plexopathy.[13,14]
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206 In conclusion, despite compressive neuropathies generally being held as rare complications of IV
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207 with PP, evidence brought up by the recent SARS-CoV-2 pandemic has shown that such conditions

208 are more frequent than previously understood. Risk factors should be carefully identified and taken
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209 into account to prevent nerve damage. Based on this limited experience, patients with one or more
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210 risk factors and poor BMI should undergo shorter PP cycles to reduce the risk of plexopathy. More
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211 investigations and retrospective studies are needed to define the exact prevalence of this

212 complication.

213

214 REFERENCES

215 1. Kallet RH (2015) A Comprehensive Review of Prone Position in ARDS. Respir Care 60
216 (11):1660-1687. doi:10.4187/respcare.04271
217 2. Carsetti A, Damia Paciarini A, Marini B, Pantanetti S, Adrario E, Donati A (2020) Prolonged
218 prone position ventilation for SARS-CoV-2 patients is feasible and effective. Crit Care 24 (1):225.
219 doi:10.1186/s13054-020-02956-w
220 3. Goettler CE, Pryor JP, Reilly PM (2002) Brachial plexopathy after prone positioning. Crit Care 6
221 (6):540-542. doi:10.1186/cc1823
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222 4. Telias I, Katira BH, Brochard L (2020) Is the Prone Position Helpful During Spontaneous
223 Breathing in Patients With COVID-19? JAMA. doi:10.1001/jama.2020.8539
224 5. Brugliera L, Spina A, Castellazzi P, Cimino P, Tettamanti A, Houdayer E, Arcuri P, Alemanno F,
225 Mortini P, Iannaccone S (2020) Rehabilitation of COVID-19 patients. J Rehabil Med 52
226 (4):jrm00046. doi:10.2340/16501977-2678
227 6. Iannaccone S, Alemanno F, Houdayer E, Brugliera L, Castellazzi P, Cianflone D, Meloni C,
228 Ambrosio A, Mortini P, Spina A, Filippi M (2020) COVID-19 rehabilitation units are twice as
229 expensive as regular rehabilitation units. J Rehabil Med. doi:10.2340/16501977-2704
230 7. Iannaccone S, Castellazzi P, Tettamanti A, Houdayer E, Brugliera L, de Blasio F, Cimino P, Ripa
231 M, Meloni C, Alemanno F, Scarpellini P (2020) Role of Rehabilitation Department for Adult

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232 Covid-19 Patients: The Experience of the San Raffaele Hospital of Milan. Arch Phys Med Rehabil.
doi:10.1016/j.apmr.2020.05.015

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234 8. Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V, Malacrida R, Di Giulio
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P, Fumagalli R, Pelosi P, Brazzi L, Latini R, Prone-Supine Study G (2001) Effect of prone
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236 positioning on the survival of patients with acute respiratory failure. N Engl J Med 345 (8):568-573.
237 doi:10.1056/NEJMoa010043
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238 9. Lucchini A, Bambi S, Mattiussi E, Elli S, Villa L, Bondi H, Rona R, Fumagalli R, Foti G (2020)
239 Prone Position in Acute Respiratory Distress Syndrome Patients: A Retrospective Analysis of
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240 Complications. Dimens Crit Care Nurs 39 (1):39-46. doi:10.1097/DCC.0000000000000393

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241 10. Bein T, Bischoff M, Bruckner U, Gebhardt K, Henzler D, Hermes C, Lewandowski K, Max M,
242 Nothacker M, Staudinger T, Tryba M, Weber-Carstens S, Wrigge H (2015) S2e guideline:
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243 positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision
244 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine
245 (DGAI). Anaesthesist 64 Suppl 1:1-26. doi:10.1007/s00101-015-0071-1
246 11. Hur K, Price CPE, Gray EL, Gulati RK, Maksimoski M, Racette SD, Schneider AL,
247 Khanwalkar AR (2020) Factors Associated With Intubation and Prolonged Intubation in
248 Hospitalized Patients With COVID-19. Otolaryngol Head Neck Surg:194599820929640.
249 doi:10.1177/0194599820929640
250 12. Papagianni A, Oulis P, Zambelis T, Kokotis P, Koulouris GC, Karandreas N (2008) Clinical and
251 neurophysiological study of peroneal nerve mononeuropathy after substantial weight loss in patients
252 suffering from major depressive and schizophrenic disorder: Suggestions on patients' management.
253 J Brachial Plex Peripher Nerve Inj 3:24. doi:10.1186/1749-7221-3-24

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254 13. Brugliera L, Spina A, Castellazzi P, Cimino P, Arcuri P, Negro A, Houdayer E, Alemanno F,
255 Giordani A, Mortini P, Iannaccone S (2020) Nutritional management of COVID-19 patients in a
256 rehabilitation unit. Eur J Clin Nutr 74 (6):860-863. doi:10.1038/s41430-020-0664-x
257 14. Yildiran H, Macit MS, Ozata Uyar G (2018) New approach to peripheral nerve injury:
258 nutritional therapy. Nutr Neurosci:1-12. doi:10.1080/1028415X.2018.1554322

259

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 Weight loss
Gender/Age Days of MUST at
Case Comorbidities (% loss in the last 3 Nerve injuries
(years) pronation hospitalization
months)
BIL axonotmesis C5 root; BIL axonotmesis
1 M/40 H 20 Kg (-18.3) 17 2
ulnar nerve at elbow

2 M/55 None 8 Kg (-10) 7 0 BIL neuroapraxia of ulnar nerve at elbow

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3 M/47 None 10 Kg (- 11.2) 19 0 L axonotmesis of ulnar nerve at elbow

pr
4 M/51 D 10 Kg (- 13.3) 14 2 L brachial plexopathy

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L lumbosacral plexopathy or L4-L5-S1

Pr
5 M/61 TT 20 Kg (-18.1) 9 2 radiculopathy; R brachial plexopathy or
C5-C6-C7 radiculopathy

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R neuroapraxia of ulnar nerve at elbow; R

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6 M/76 H, D, CRF 17 Kg (-18.2) 16 2 axonotmesis of peroneal nerve at the

u popliteal fossa/fibular head

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7 M/43 H 10 Kg (12) 13 2 R axonotmesis of ulnar nerve at elbow

Table 1. Summary of clinical characteristics of the series

Legend. M: Male; H, Hypertension; D: Diabetes mellitus; TT; Thalassemia trait; CRF: Chronic Renal Failure; O: Obesity; MUST: Malnutrition
Universal Screening Tool; L: Left; R: Right; BIL: Bilateral.