Printer Friendly

A cross-sectional survey of hemodialysis patients on their preference for arm vs. thigh grafts.

INTRODUCTION

Patients with advanced Chronic Kidney Disease (CKD) are generally starting dialysis earlier and surviving longer than three or four decades ago. (1) Hemodialysis patients require a well-functioning vascular access for their survival. As arteriovenous fistulas and synthetic grafts are first placed in the upper extremities as per the National Kidney Foundation Kidney Diseases Outcomes Quality Initiative (K/DOQI) clinical practice guidelines, (2) many hemodialysis patients tend to exhaust their arm access sites after a few years on dialysis. Others do not have arm access sites suitable for, or have had several failed attempts at, arm fistula and/or graft placements (15-20 percent of patients in many studies). (3,4) When patients run out of arm access sites, the question arises, what should be done next? In these situations, the options are placement of tunneled dialysis catheters (TDCs) or thigh grafts. Recent studies have suggested that synthetic grafts placed in the lower extremity at the thigh location are a preferable alternative to TDCs. These studies have shown that thigh grafts (which have lower primary failure rates compared to fistulas) provide long-term, complication-free survival which is significantly better than arm grafts and equivalent to mature fistulas. (5,6,7,8)

At our institution, the decision to place a thigh graft in kidney dialysis patients is often made in our vascular access conference by the interventional nephrologists and surgeons, after reviewing the patients' access history and other clinical factors. The views of the patient on access location are often not considered in this process of decision-making at the individual patient level --despite living in an era of patient-centered care. From the patient perspective, thigh grafts involve greater invasion of privacy at the time of graft cannulation and subsequent monitoring during dialysis, as compared to arm accesses. It is possible that patients may have a strong prejudice against thigh grafts, and their concerns may be different from those of the nephrologists and surgeons.

It is not clear what patients themselves would prefer in terms of the site of their dialysis access. There is little information in the literature regarding patients' views and preference for thigh grafts in particular, or even about patient preference for the site of their dialysis access in general. In a survey of 128 patients, Bay et al. (9) found that most patients preferred arm accesses, and ranked accesses in the femoral region as the worst. Furthermore, patients desired a superficial access in the forearm that was easy to cannulate, had minimal effect on their appearance, enabled arm comfort during dialysis, and provided quick homeostasis after dialysis. However, the preferences of doctors and nurses often differed from those of the patients themselves.

This paucity of published studies on patient preference has more than mere academic importance; presumably, patients are more likely to proceed with placement of an access and ensure good care of it if they are have a role to play in its selection. Previous studies have shown that patients with limited knowledge on the subject of dialysis may be less likely to use an arteriovenous fistula or graft as permanent access for dialysis --both at initiation of hemodialysis, and in the phase of chronic maintenance dialysis. (10) Also, other research has shown that limited or low health literacy is associated with a higher risk of mortality in incident ESRD patients. (11)

The goal of this study was to determine if patients already on hemodialysis had a preference for a graft in the arm v. a graft in the thigh as the location of a future access site, particularly if arm access sites were unavailable. Considering that the patients' education level and prior experience with grafts and fistulas may modulate this preference, we also attempted to determine if the preference reported by patients was influenced by these and other demographic factors.

PATIENTS AND METHODS

The study was approved by the Institutional Review Board, and was therefore performed in accordance with the ethical standards laid down in the Declaration of Helsinki, 2000, as well as the Declaration of Istanbul, 2008. It was conducted at 13 dialysis units in the Shreveport and surrounding area from December 2010-October 2011. Hemodialysis patients in these units who were under the care of nephrologists at the Louisiana State University Health Sciences Center, Shreveport, LA (LSUHSC-S), were approached for study participation. The survey itself was conducted by one investigator (Dr. Abro), who explained the study to patients, obtained informed consent from them prior to their inclusion in the study, and also provided assistance to patients in filling out the questionnaire if necessary.

Table 1 illustrates the questionnaire that was specially developed for use in this cross-sectional survey. The questionnaire asked patients to provide information on their age, gender, level of education and access history (including current and prior fistulas, arm grafts and thigh grafts, and also the total number of years on dialysis). Finally, patients were asked whether they would prefer an arm graft or a thigh graft as their next access, if all other factors were equal. Most demographic and access information was confirmed from patients' charts. However, education levels were recorded as reported by the patients themselves, and no attempt was made at further verification.

Statistical analysis: Data is presented as mean [+ or -] SD or N (%), and analyzed using JMP 9.0 statistical software from SAS Institute Inc., NC, USA. Categorical variables were compared using the chi-squared test; continuous variables with the t-test. Multivariate logistic regression analysis was used to determine the influence of various factors on patient-reported thigh graft preference. Significance was set at P < 0.05.

RESULTS

Most of the approximately 250 hemodialysis patients who were under the care of our group at 13 dialysis units were approached for participation in the study survey. A total of 196 (78 percent) gave informed consent and completed the questionnaire provided. Table 2 summarizes the demographics, level of education and access history of study patients.

In terms of dialysis vintage, 96 percent had been on dialysis [greater than or equal to] 1 year; 35 percent had been on dialysis for longer than 5 years, correlating with the relatively younger age of our patient population.

Overall, 90 percent of patients preferred a graft in the arm as the next access (176/196), but 10 percent said they would go for a graft in the thigh (Table 3). For purposes of further analysis, we then divided the patients into two groups--the arm graft preference group and the thigh graft preference group--in an effort to elucidate the factors that were associated with thigh graft preference. We used multivariate logistic regression analysis to determine the influence of various factors on patient-reported thigh graft preference. Patient age and race were found to be non-significant as a determinant of preference for thigh grafts (P = 0.37 and 0.45 respectively). Patients' dialysis vintage (both as numerical value and also by category) at the time of survey was similar in the two preference groups. In short, patients' age, race, particular dialysis unit and dialysis vintage did not seem to influence patient preference.

More females had a tendency to prefer thigh grafts compared to males, 15.5 percent v. 7 percent (P = 0.0575). Also, females were more likely to have had at least one thigh graft for vascular access (11 percent v. 5 percent, P = 0.08), so the preference of females may be related to their experience of or exposure to thigh grafts.

Thigh graft preference was not influenced by the patients' level of education (Table 2). Less than 16 percent patients preferred thigh grafts in any of the sub-groups as defined by their level of education (P = 0.30). This conclusion did not change if the education level was categorized into only 2 groups, not completed high school v. completed high school or higher (including college) - 13 percent vs. 9 percent patients, respectively, preferred thigh grafts (P = 0.50; Figure 1).

We found that 50 percent of patients dialyzing with thigh grafts at the time of survey did prefer thigh grafts, as compared to patients using fistulas, arm grafts and catheters at time of survey (7, 0 and 16 percent respectively, P = 0.001) (Table 3 and Figure 2). However, the number of such thigh grafts in the study is low (6 out of 140, 4 percent of total permanent accesses).

Total number of accesses per patient was similar in both groups (range 0-7). Patients with one or more fistulas ever were as likely to prefer thigh grafts as patients who never had a single fistula (approx. 10 percent each, P = 0.92). Patients with one or more grafts ever were as likely to prefer thigh grafts as patients who never had a single graft (approximately 10 percent each, P = 0.87). Patients with catheter(s) as their only access ever were as likely to prefer thigh grafts as patients who had had fistulas and/or grafts (6.7 percent v. 10.5 percent, P = 0.64). However, patients who had had experience with at least one thigh graft were more likely to prefer thigh grafts compared to those patients who had never had a thigh graft (36 percent v. 8 percent, P = 0.001) (Figure 3).

DISCUSSION

NKF K/DOQI clinical practice guidelines for vascular access recommend preferential placement of arteriovenous fistulas (AVF) in hemodialysis patients, with AV grafts being reserved for patients whose vascular anatomy precludes fistula placement. (2) The rationale for this recommendation is that fistulas require substantially fewer interventions than do grafts to maintain long-term patency for dialysis, ensuring dialysis adequacy and better patient outcomes. Grafts, however, are a better alternative in general than catheters for patients in whom an attempt at AVF creation either failed or could not be tried for different reasons; (12) these advantages include better outcomes in terms of infection, thrombosis and long-term survival and patency. More specifically, Allon et al. have long opined that placement of thigh grafts should be thought of as a viable alternative to long-term catheters among hemodialysis patients who have exhausted all options for a permanent vascular access in both upper extremities. (6,13)

In theory, the thigh graft has certain advantages. It may be cosmetically preferable to upper extremity grafts and fistulas because it is generally hidden from view when not in use. In the era of increasing numbers of patients on home hemodialysis, such patients could easily self-cannulate the thigh graft, with both arms being free for use during dialysis sessions. On the other hand, cannulation of the thigh graft by dialysis personnel and the need for frequent observation of the graft during in-center hemodialysis sessions may result in an invasion of the patient's privacy.

The question arises, would patients prefer a thigh graft over an arm graft if an upper extremity fistula could not be constructed? As it turns out, patients' views and preference for thigh grafts are largely unknown at present, and have not been systemically evaluated. In the current era of patient-centered care, this represents a gap in our knowledge and implies that patient preferences are potentially not being addressed as regards access location. This question has more than academic value; it has great practical and clinical significance. After all, as most clinicians know, our patients are more likely to agree to placement of an access and take good care of it if they are have a role to play in its selection and in the decision-making process. (10,11) Therefore, the present study was needed to fill in some of the gaps in our current knowledge. Our cross-sectional survey was conducted on patients currently on hemodialysis (n=196), who were queried regarding their preference for access location (thigh graft v. arm graft) if all other factors were equal.

Given the higher prevalence of arm accesses in our study, it was not surprising that 176 of 196 (90 percent) patients reported a preference for an arm graft over a thigh graft--which conforms to general practice as well. This may be due to patients' prejudice against lower extremity access, likely due to factors such as its close proximity to the groin area, etc.

However, this study shows that in a subset of patients in whom upper extremity AV access is not an option, patients seem to have a more accepting attitude towards thigh grafts. Our data shows a 50 percent rate of thigh graft preference in patients utilizing a thigh graft at the time of the survey (P = 0.001)--the limitation being low numbers in this patient subset in our study (6 thigh grafts, or 4 percent of the total permanent accesses). Patients who had an access history of one or more thigh grafts had a higher likelihood of preferring thigh grafts over upper extremity grafts, as compared to those patients who had never had a thigh graft (36 percent v. 8 percent, P = 0.001)--possibly influenced by favorable past experience with thigh grafts, and possibly for cosmetic and esthetic reasons as the graft is hidden from the public eye.

As the average age at initiation of HD in the US is 63 years, (14) this is in comparison a relatively younger dialysis population --taking into account our mean patient age of 53 years and the fact that many of them are prevalent (not just incident) patients. With the exception of 7 patients (3.6 percent) who were relatively new to dialysis, the majority of patients had been on dialysis either one-to-five years (62 percent) or over 5 years (35 percent), with a maximum dialysis vintage of 21 years. This indicates opportunity for reasonable exposure to access placement and complications for the study population as a whole.

More females had a tendency to prefer thigh grafts compared to males, 15.5 percent v. 7 percent (P = 0.0575). This finding may be somewhat surprising at first sight, but we found that females were also more likely to have had at least one thigh graft for vascular access (11 percent v. 5 percent, P = 0.08). The latter finding may be related to females having arteries and veins that are relatively smaller in size, leading to more complications and eventually exhaustion of access sites in the upper extremities culminating in a higher rate of thigh graft placement. Hence, the preference of females may be related to their greater exposure to thigh grafts.

Most patients (81 percent) had completed high school or higher education. This figure is comparable to that found (86 percent) in the study by Green et al. (15) However, the education level of patients was self-reported, and it was not possible for the investigators to independently confirm what the patients stated. Our study shows that thigh graft preference was not influenced by the patients' level of education (Table 3).

Access prevalence at the time of survey was 55 percent fistulas, 16 percent synthetic grafts, and 29 percent tunneled dialysis catheters (TDCs). These proportions closely reflect the access prevalence at our center and our ESRD network. Prevalent rates of vascular access in ESRD Network 13 as of September 2010 (the time period most relevant to our survey) are: AVF 56 percent, AVG 20 percent and TDC 24 percent. (16) As expected, thigh graft prevalence was low (6 of 196 patients or 3 percent) --with arm graft prevalence being 13 percent. In order to determine the overall experience of patients with each access type, we asked whether they had ever had a fistula, arm graft or thigh graft during their entire time on dialysis. Although the percentage of patients who had fistula and arm grafts now increased to 79 and 21 percent respectively, the percentage of thigh grafts recipients doubled (7 percent). This shows that at our center, patients are considered for thigh graft placements when arm access sites fail. Table 2 also shows that 92 percent patients had used fistulas and/or grafts at some point--only 8 percent patients had never had a permanent access at all. As this was a cross-sectional survey, we could not establish whether this catheter-dependency was due to lack of attempts at access placement or a result of primary access failure(s).

Of even greater importance, we noted that the prevalent utilization of AVFs was 55 percent and that 29 percent of our patients were using tunneled dialysis catheters--in the era of Fistula First. It is generally recognized that a consequence of the Fistula First Initiative has been greater use of TDCs, due to the fact that many patients are not candidates for fistulas and also reflecting the length of time spent on TDCs whilst awaiting fistula maturation. The 29 percent patients using tunneled dialysis catheters at the time of survey, and particularly the 8 percent who never had any permanent access, are prime candidates for moving away from TDCs to fistulas, arm grafts, and failing these, to thigh grafts. Thigh grafts may represent an opportunity to attain permanent vascular access in such patients.

Our study does have certain limitations. This is a cross-sectional patient-preference survey; a longer-term study done prospectively may conceivably yield different results. Moreover, it is a single-center study performed at the various outpatient dialysis centers associated with LSUHSC-S, and our results may not necessarily be generalizable to all dialysis centers. We have previously shown that our local Southern dialysis population has significant differences from the overall American DOPPS cohort in terms of demographics and dialysis adherence. (17) The number of patients in this study is relatively small (n=196), by virtue of its single-center nature. Also, the number of patients with either current or prior exposure to thigh grafts is also small--though the proportion of arm grafts and fistulas is similar to that noted in most other studies investigating thigh grafts. Including a larger number of patients, e.g., by a multi-center trial, would increase the number of patients with exposure to thigh grafts.

Furthermore, the education level of the patients was self-reported and was not able to be independently confirmed. This was a survey, and we obtained patients' answers to all questions including age, education level, dialysis duration and access history. Only some of the information was independently confirmed--e.g., their age, gender and race. Also, the survey did not inquire into the reasons why patients preferred arm v. thigh grafts, or attempt to determine the patients' satisfaction with a particular access type or location. Finally, we could not ascertain the status of the patients' health education, which may have an important bearing on their choice of access. These may be important considerations to be addressed in future investigations.

There exists a subset of ESRD patients that experiences multiple vascular access failures to the point that they exhaust options for further permanent access in the upper extremities. In such patients, continued hemodialysis requires either placement of a thigh graft or prolonged use of tunneled dialysis catheter(s). Given the frequent infectious and thrombotic complications of dialysis catheters, a thigh graft would seem to be the better option. Outcomes such as adequacy of dialysis, blood flow rates, rate of infection and access survival (intervention-free survival, thrombosis-free survival, and cumulative survival) are actually similar between thigh and upper extremity grafts. (5) Nephrologists and vascular surgeons should therefore consider thigh grafts in those patients in whom upper extremity vascular access has been exhausted, as they provide better alternative permanent access as compared to tunneled dialysis catheters.

This study has attempted to evaluate patients' views and preference for thigh grafts--thereby addressing a paucity of literature on this particular subject, and helping to fill in some of the gaps in our current knowledge of patients' preference for access location. This is important, given the current emphasis on patient-centered care in the United States. It shows that in the subset of patients in whom upper extremity AV access is not an option, patients seem to have a more accepting attitude towards thigh grafts. Hence, we as a physician community should expend more effort at educating patients on the benefits of thigh grafts in this setting. Indeed, with greater patient education on their survival and other benefits, thigh grafts may gain increased and wider acceptance.

In conclusion, the likelihood of patient preference for placement of a thigh graft was increased if the patient had a current or previous thigh graft--apparently being influenced by a possibly favorable experience with thigh grafts. Demographic factors (e.g., age and race), level of education and dialysis vintage seemed not to influence patient preference. As thigh grafts are a better option than tunneled dialysis catheters in patients who have exhausted all upper extremity access sites, nephrologists should consider thigh grafts in this sub-group, and more efforts at educating patients on the benefits of thigh grafts in this setting are warranted.

REFERENCES

(1.) Port FK, Orzol SM, Held PJ, Wolfe RA. Trends in treatment and survival for hemodialysis patients in the US. Am J Kidney Dis 1998;32(suppl 4):S34-S38.

(2.) NKF K/DOQI clinical practice guidelines for vascular access. Am J Kidney Dis. 2006;48;(suppl 1):S248-S273, 2006.

(3.) Akoh JA, Sinha S, Dutta S, Opaluwa AS, Lawson H, Shaw JF, Walker AJ, Rowe PA, McGonigle RJ. A 5-year audit of hemodialysis access. Int J Clin Pract. 2005;59:847-851.(PubMed: 15963214).

(4.) Flarup S, Hadimeri H. Arteriovenous PTFE dialysis access in the lower extremity: A new approach. Ann Vasc Surg. 2003;17:581-584.(PubMed: 14738088).

(5.) Ram SJ, Sachdeva BA, Caldito GC, Zibari GB, Abreo KD. Thigh grafts contribute significantly to patients' time on dialysis. Clin J Am Soc Nephrol. 2010 Jul;5(7):1229-34.

(6.) Miller CD, Robbin ML, Barker J, Allon M. Comparison of arteriovenous grafts in the thigh and upper extremities in hemodialysis patients. J Am Soc Nephrol. 2003;Nov;14(11):2942-2947.

(7.) Schild AF, Perez E, Gillaspie E, Seaver C, Livingstone J, Thibonnier A. Arteriovenous fistulae vs. arteriovenous grafts: A retrospective review of 1,700 consecutive vascular access cases. J Vasc Access 2008;9:231-235. (PubMed: 19085891).

(8.) Snyder DC, Clericuzio CP, Stringer A, May W. Comparison of outcomes of arteriovenous grafts and fistulas at a single Veterans' Affairs medical center. Am J Surg. 2008;196:641-646. (PubMed: 18823616)

(9.) Bay WH, Van Cleef S, Owens M. The hemodialysis access: preferences and concerns of patients, dialysis nurses and technicians and physicians. Am J Nephrol. 1998;18(5):379-383.

(10.) Cavanaugh KL, Wingard RL, Hakim RM, Elasy TA, Ikizler TA. Patient dialysis knowledge is associated with permanent arteriovenous access use in chronic hemodialysis. Clin J Am Soc Nephrol. 2009 May;4(5):950-956.

(11.) Cavanaugh KL, Wingard RL, Hakim RM, Eden S, Shintani A, Wallston KA, Huizingal MM, Elasy TA, Rothman RL. Low health literacy associates with increased mortality in ESRD. J Am Soc Nephrol. 2010;21:1979-1985.

(12.) Ethier J, Mendelssohn DC, Elder SJ, Hasegawa T, Akizawa T, Aikiba T, Canaud BJ, Pisoni RL. Vascular access use and outcomes: an international perspective from the dialysis outcomes and practice patterns study. Nephrol Dial Transpl. 2008;23:3219-3226.

(13.) Harish A, Allon M. Arteriovenous graft infection: a comparison of thigh and upper extremity grafts. Clin J Am Soc Nephrol. 2011 Jul;6(7):1739-43.

(14.) 2011 US Renal Data System Annual Report

(15.) Green JA, Mor MK, Shields AM, Sevick MA, Palevsky PM, Fine MJ, Arnold RM, Weisbord SD. Prevalence and demographic and clinical associations of health literacy in patients on maintenance hemodialysis. Clin J Am Soc Nephrol. 2011 Jun;6(6):1354-1360.

(16.) ESRD Network 13-2010 Annual Report--Appendix B-pages 3-4, and 9.

(17.) Tapolyai M, Fulop T, Uysal A, Lengvarszky Z, Szarvas T, Ballard K, Dossabhoy NR. Regional differences in nonadherence to dialysis among southern dialysis patients: a comparative cross-sectional study to the dialysis outcomes and practice patterns study. Am J Med Sci. 2010 Jun;339(6):516-518.

Neville R. Dossabhoy, MD and Zulqarnain Abro, MD

Drs. Dossabhoy and Abro are both associated with the Nephrology Department, Louisiana State University Health Sciences Center, Shreveport, LA and the Nephrology Department of the Veterans Affairs Medical Center, Shreveport, LA.

Table 1: Patient preference questionnaire developed and used in the
study.

1.     Gender                                 -- Male   -- Female
2.     Age                                    -- Years
3.     How long have you been on dialysis?    -- Years
                                              -- No High School
                                              -- Some High School
4.     How far did you get in school?         -- Finished High School
                                              -- Some College
                                              -- Finished College
5.     Are you on dialysis now?               -- Yes    -- No
                                              -- Arm fistula
6.     If yes, what dialysis access are you   -- Arm Graft
       using now?                              -- Thigh graft
                                               -- Catheter
7.     Do you have a fistula/graft in the
       arm now?                                -- Yes   -- No
8.     Have you ever had a fistula/graft in
       the arm/thigh?                          -- Yes   -- No
9.     How many fistulas/grafts have you
       ever had (in the arm + thigh)?
10.    Have you ever had a graft in the
       thigh?                                 -- Yes    -- No
11.    If all other factors were equal,       -- A graft in the arm
       with the same medical results and      -- A graft in the thigh
       medical indications, which one would
       you prefer?

([dagger]) As patients could be included in >1 of these categories,
the total exceeds 196.

Table 2: Patient demographics and access history of study patients.

                                             Mean [+ or -] SD or N (%)

Number of patients                           196
Patient age (years)                          53 [+ or -] 13
African Americans                            183 (93%)
Females                                      70 (36%)
Level of education:
      No high school                         5 (2.6%)
      Some high school                       33 (16.8%)
      Finished high school                   107 (54.6%)
      Some college                           37 (18.9%)
      Finished college                       14 (7.1%)
Dialysis vintage:
      Less than 1 year                       7 (3.6%)
      1 to 5 years                           121 (61.7%)
      More than 5 years (range 6-21 years)   68 (34.7%)
Access use on date of survey
      Fistula                                108 (55%)
      Arm graft                              26 (13%)
      Thigh graft                            6 (3%)
      Tunneled Dialysis Catheters (TDCs)     56 (29%)
Access history of study patients t
      At least 1 fistula                     155 (79%)
      At least 1 arm graft                   42 (21%)
      At least 1 thigh graft                 14 (7%)
      No fistulas or grafts ever (TDCs
        only)                                15 (8%)

TABLE 3. Factors associated with thigh graft preference

                                        Preferred         Preferred
                                      arm grafts (a)   thigh grafts (a)

Number of patients                    176 (90%)        20 (10%)
Patient age on date of survey (yrs)   53 [+ or -] 13   50 [+ or -] 14
African American race                 166 (94%)        18 (90%)
Gender
Females                               59 (37%)         11 (55%)
Males                                 117 (66%)        9 (45%)
Level of education
Some high school or lower             33 (87%)         5 (13%)
Finished high school or higher        143 (91%)        15 (9%)
Dialysis vintage
Less than 1 year                      6 (3%)           1 (5%)
1 to 5 years                          111 (63%)        10 (50%)
More than 5 years                     59 (34%)         9 (45%)
Access use on date of survey
Fistula                               100 (93%)        8 (7%)
Arm graft                             26 (100%)        0 (0%)
Thigh graft                           3 (50%)          3 (50%)
Catheter                              47 (84%)         9 (16%)
Access history of study patients
At least 1 fistula                    139 (90%)        16 (10%)
At least 1 arm graft                  38 (90%)         4 (10%)
At least 1 thigh graft                9 (64%)          5 (36%)
No fistulas or grafts ever            14 (93%)         1 (7%)
  (catheters only)

                                      P value (b)

Number of patients
Patient age on date of survey (yrs)   0.37
African American race                 0.45
Gender                                0.0575
Females
Males
Level of education                    0.50
Some high school or lower
Finished high school or higher
Dialysis vintage                      0.52
Less than 1 year
1 to 5 years
More than 5 years
Access use on date of survey          0.001
Fistula
Arm graft
Thigh graft
Catheter
Access history of study patients
At least 1 fistula                    0.92
At least 1 arm graft                  0.87
At least 1 thigh graft                0.001
No fistulas or grafts ever            0.64
  (catheters only)

(a) Values are Mean [+ or -] SD or N (%)

(b) Multivariate logistic regression analysis was used to
determine the influence of various factors on patient-reported
thigh graft preference

Figure 3.  Patients with experience of thigh grafts were more likely to
prefer thigh grafts.

THIGH GRAFT EXPERIENCE      % OF PATIENTS

No thigh graft ever               8
One or more thigh grafts         36

Note: Table made from bar graph.
COPYRIGHT 2015 Louisiana State Medical Society
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2015 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Dossabhoy, Neville R.; Abro, Zulqarnain
Publication:The Journal of the Louisiana State Medical Society
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2015
Words:4637
Previous Article:Using simulation-based training to incorporate thoracic ultrasound into physical examination.
Next Article:ECG in an 81-year-old woman.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters