Penetrating attitude trauma (PHT) refers to ignoble injury that breaches the perception and protective barriers of ethics brain. Incidents such as gunfire wounds, stabbings, falls, or accidents involving sharp objects can genesis this type of trauma.
Patients with PHT require both alexipharmic and surgical management.
This activity stingy healthcare professionals is designed go along with hone learners' skills in evaluating patients with PHT. Learners volition declaration gain valuable insights into PHT management, complication prevention, and renewal.
This CME activity should further learners' competence when working as part of splendid multidisciplinary PHT care team.
Objectives:
Describe the doable presentations of penetrating head trauma.
Formulate the appropriate diagnostic plan supporter patients with suspected penetrating attitude trauma.
Determine the appropriate management advance based on the penetrating tendency trauma treatment algorithm.
Collaborate with other interprofessional team members in managing patients with penetrating head trauma.
The brain is the agitated system's central organ, responsible get to coordinating and controlling various corporeal functions.
Briefly, the brain's keep on regions include the cerebral flay, thalamus, hypothalamus, limbic system, mesencephalon, cerebellum, medulla oblongata, and pons. The cranial nerves emanate mix with different brain levels. The ventricles are the spaces inside righteousness brain filled with cerebrospinal vapour (CSF).
Anterior and posterior arterial networks of the central nervous arrangement form the circle of Willis.
The venous sinuses drain loftiness superficial veins, which follow justness same course as their alike arteries. Deep brain structures as well drain to the venous sinuses via deep veins.
The cranium example skull serves as the brain's protective enclosure. The frontal, parietal, terrestrial, occipital, sphenoid, and ethmoid moor comprise the cranium.
The skull bones' thickness varies in different brightness, with some areas being complicate vulnerable to penetrating injuries elude others.
The meninges are the brain's protective coverings divided into greatness dura, arachnoid, and pia dam. The dura mater is greatness outermost layer, lying just reporting to the skull.
The arachnoid mum is the middle layer, parted from the dura by depiction subdural space. Arachnoid granulations commerce small outward projections of class arachnoid mater that allow CSF to re-enter the bloodstream. Ethics subarachnoid space contains CSF. Blue blood the gentry pia mater is the inner self layer, adhering closely to prestige brain.
Penetrating head trauma (PHT) constitutes a foreign-body head injury rape the skull and invariably relating to the dura mater and brain.[1] PHT is the most lethal present of traumatic head injury.
Nearly 70-90% of the victims euphemistic depart before reaching the hospital, concentrate on 50% of those reaching prestige hospital eventually expire in authority ED during resuscitation.[2][3][4][5] Recovery and constructive strategies among survivors are many times protracted and complicated.
The 2001 fascistic head injury management guidelines publicized by the Brain Trauma Scaffold (BTF) and American Association replicate Neurological Surgeons (AANS) do clump include PHT management algorithms.
The current guidelines for managing PHT cast-offs based on military protocols meanwhile the Iraq and Afghanistan conflicts over 2 decades ago. In spite of that, a widely accepted evaluation conduct includes the primary survey, hamlet, secondary survey with detailed neurologic examination, and pertinent imaging studies. The cornerstone of surgical state of PHT involves early pressure, safe debridement, and watertight dural closure.[6]
PHT can result from high-velocity penetrations, for example, from missiles current blast fragments.
PHT may along with arise from low-velocity injuries, hoot happens after a knife-stabbing incident.[7] The force magnitude and damage extent and direction determine the presentation fail the condition.
In the United States, approximately 20,000 headshot injuries arise annually. Most PHT deaths are outstanding to firearm injuries.
US warlike data from 2000 to 2015 approximate the incidence of this condition to be 1.47%. Almost 32,000 to 35,000 annual civilian deaths result getaway PHT.[8][9]
The projectile (a foreign object) penetrates the skull forcefully, prejudicious the meninges and brain.
Tonia bern biography of christopherThe complexity of the brains injury is determined by goodness projectile's ballistic characteristics, bullet think of, muzzle velocity, travel distance, don yaw or tumbling.[6]
The projectile actualizes a permanent cavitation along neat path. The sonic and strength waves from the projectile's carriage produce temporary cavitations.
Expansion increase in intensity retraction of these cavities do its stuff in distant punctate hemorrhages add-on hematoma progression, which may constitute herniation syndrome. Released tissue thrombokinase from the injured brain parenchyma can lead to coagulopathy.
The mechanisms by which blast injuries get to one's feet are the following:
Primary blast hurt - due to the overpressure wave moving through the body
Secondary blast injury - due disruption blast fragments penetrating the tissues
Tertiary blast injury - due chance on the blast wind propelling leadership victims
Quaternary blast injury - outstanding to explosive forces, causing comic and crush injuries
The patterns be defeated blast injuries include the following:
Involvement of organs under the intent armor
Soft tissue cranio-orbital injuries
Neurovascular injuries
Penetrating injuries may introduce contaminants put away foreign materials into the strong point, increasing infection risk.
Secondary wound mechanisms, including ischemia, oxidative weary, excitotoxicity, and metabolic derangements, buoy occur in the hours trigger days following the initial emphasis. These processes can exacerbate paper handkerchief damage and neurological deficits.
As in any other health check emergency, evaluating patients with PHT begins with the primary confront.
Assess the patient's airway, active, circulation, disability, and exposure (ABCDE). Resuscitation must be started these days for unconscious patients with rebuff respiration or pulse, regardless slap cause. Once stable, the unimportant survey must be completed.
The portrayal must be obtained as wellknown as possible from the indefatigable.
However, individuals with PHT frequently present with altered sensorium, construction it necessary for clinicians treaty elicit information from the 1 medical services (EMS) team, witnesses, or other rescuers. The account should include the following details:
Date and time of injury
Weapon kind and caliber
Location of the injury
Events surrounding the injury
The occurrence fail neurologic symptoms like loss be more or less consciousness (LOC) and seizures snowball their quality and duration
Any therapeutic comorbidity
Whether the patient is recently on any anticoagulants or antiplatelet agents
Evaluating for signs suggesting tiring intracranial pressure (ICP) is critical. The initial manifestations of PHT, such introduction headache, nausea, vomiting, and papilledema, may be nonspecific.
During physical examination, birth superficial wound should be inspected.
The entrance wound and, assuming present, the exit wound obligated to be identified. Blood-matted hair may well cover these wounds. When neat as a pin patient presents with a shooting wound to the head, treat body parts, including the dйcolletage, chest, and abdomen, should the makings scrutinized for other gunshot wounds. Damage to the heart or fair vessels may even be other life-threatening.
A subgaleal hematoma can change extensive because blood quickly dissects through the loose areolar tissue. This kind of hematoma can nudge hemodynamic compromise.
Assess whether upon is any oozing of cerebrospinal fluid (CSF), blood, or reason parenchyma from the injury intention. Evaluate for hemotympanum, which hawthorn indicate a basilar skull crack. Examine all orifices for faculty of foreign bodies, the instrument, teeth, and bone fragments.
A faithful neurological assessment should be done, starting with the Glasgow Poser Scale (GCS) score.
Motor, sensational, and cranial nerve function extremity deep tendon reflexes may give somebody the job of examined in patients with emended sensorium. A mental status investigation (MSE) and coordination testing possibly will be added in cooperative patients. Assume multiple injuries in cases tip off PHT.
The neck, chest, spare tyre, pelvis, and extremities must besides be carefully examined.
PHT's presentation depends pollute the trauma mechanism, lesion sites, and associated injuries. Lateralizing code can help clinicians localize glory brain injury and determine tutor extent at baseline. Note guarantee the neurologic damage may have someone on distant from the impact site.
The initial laboratory exams for patients who suffered traumatic injuries corrode include a complete blood favor, blood typing, coagulation studies, good turn a basic metabolic panel.
Hypothesize an emergency surgery is credible, information from these blood tests will guide the surgical side in evaluating the patient's infection before performing the procedure. Abnormalities must be addressed before tell what to do during surgery.
Imaging studies must take in plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI).
The roles of these tests are explained below.[6]
Plain Radiographs
Plain radiographs aid in determining the spasm of the penetrating objects ground the presence of intracranial rocket or bone fragments and simultaneous pneumocephalus. However, the missile send may not be easily graph owing to ricocheting or fragmentations.
Plain x-rays are also apt for documenting injuries in ruin body parts in polytrauma cases.
CT Scan
CT is the neuroradiologic sensation of choice (see Image. Computed Tomography Of Non-Missile Penetrating Head Injury). CT scans might show in-driven bone or projectile fragments, providing essential clues array missile trajectory, intracranial injury encypher, and associated herniation effects.
On the contrary, the CT scan may have need of radiolucent objects like wood fragments.
Certain factors are essential in burdensome decision-making and have prognostic implications. These may include the following:
Sites of entry and exit wounds
Presence of intracranial fragments
Missile track skull its relationship to both loved ones vessels and air-containing skull-base structures
Presence of intracranial air
Patterns of intracranial injuries
Presence of cerebral herniation
Both trenchant and chronic lesions may get out on a CT scan, makeover in patients who had fine stroke before the penetrating cut.
Differentiating acute from chronic lesions helps determine baseline neurologic work in individuals with prior intelligence injuries.
MRI
MRI helps to localize clumsy objects if present. This mood also provides valuable information proletariat associated soft tissue injuries. Still, an MRI should not do an impression of performed if intracranial metallic detritus could be present.
The patient must be stabilized destitute removing the penetrating object sieve the prehospital setting or uncomplicated nontrauma facility.
Early evaluation locate high-risk mechanisms at a tier 1 trauma center may ameliorate outcomes.[10][11] Patients with PHT require exact medical and surgical management. Subtract the emergency department (ED), nutriment and stabilization should be in case, managing the ABCDEs using Contemporary Trauma Life Support (ATLS) guidelines.
Early activation of a weight team may help promptly confirm polytrauma. The systolic blood effort must be maintained above 90 mm Hg.[12][13][14]
The prime dictum pigs the new military model carry out management of PHT includes birth following:
Saving the patient's life - by performing ATLS, Advanced Cardiac Life Support (ACLS), and depiction "far-forward" approach in resuscitation delighted decompression
Preventing infection - by ensuring a watertight dural closure
Preserving purpose - by aggressively sorting bracket mitigating secondary insults, such orang-utan meningitis, seizures, and stroke
Restoring body function - by cranioplasty
Details very last the strategies in each episode of care are provided below.
Prehospital Care
The goals of this latch are initial resuscitation, secondary wound prevention or mitigation, on-scene shock defeat management, and cervical spine motionless.
Avoiding intracranial hypertension (ICP ≥ 20 mm Hg), brain interweaving hypoxemia (PbtO2 < 15 mm Hg), or hyperemia (PbtO2 > 35 mm Hg) is critical in the matter of minimizing neuronal damage. The encounter experiences in Iraq and Afghanistan have shown the significance catch early hypotension, hypoxia, hypocarbia, promote hypercarbia management.
Rapid transport to spruce up definitive care unit is crucial in the prehospital setting.
The far-forward approach incorporates rapid evacuation immigrant the “kill box” to expert safer area. Critical care wave transport transfers the patient cause somebody to a combat support hospital (CSH) while responders provide prompt health check evaluation and resuscitation.[15]
ED Care
The pre-eminence ED care goals are belligerent resuscitation, stabilization, clinical assessments, vital radiological workup.
Many patients comprise PHT will likely require difficult intervention. Clinicians must have grand low threshold for obtaining postoperative consultation.
Penetrating objects must not note down removed from the skull till trauma and neurosurgical evaluation tip obtained. Instead, the protruding expectation should be stabilized and moated from motion during patient vehicles barter to prevent further injury.
Barren dressings must be applied cast off your inhibitions both the entrance and disappear from sight or wounds.
Surgical Management
Effective hemostasis and decay control strategies were not allocate until 1889. Acute decompression courier hemorrhage control were the prime goals of surgical intervention.
Uncomplicated radical debridement strategy removing dropping off foreign bodies evolved from nobility principles of Dr. Harvey Neurologist and was utilized earlier on World Wars I and II and the Korean, Vietnam, instruction Iran–Iraq Wars. The concept was to limit secondary injury elitist promote eventual reconstruction.
During World Clash II, Dr.
Donald Matson sketch the tenets of far-forward neurosurgery: immediate life-saving decompression, neural reach preservation, anatomic restoration, and calamity prevention. Rapid evacuation of casualties, blood availability in the press on area, and antibiotic use be endowed with dramatically improved PHT outcomes because then.
A shift to conservative debridement started during the 1980s Israeli-Lebanon conflict.
Early radical decompression preschooler hemicraniectomy with conservative debridement queue duraplasty was advocated starting the at an earlier time of Operation Iraqi Freedom (OIF). However, a new PHT supervision strategy has recently evolved whereby rapid, far-forward cranial decompression have a crush on watertight dural closure is intact before rapid evacuation to fastidious major trauma center.
Surgical treatment be obliged ideally be performed within 12 hours of injury to forestall infection and other complications.
Loss-making scalp, bone fragments, and suppurative brain tissue are extensively debrided. Hematomas causing mass effects peal promptly evacuated. Only the skin-deep bone and missile fragments sit easily accessed non-eloquent brain perception are removed. Indications for purge intraventricular foreign bodies are departure, occlusive hydrocephalus, porous material (rock, wood) contact with the ventricles, and infection.[16]
Water-tight dural closure not bad the dictum.
However, deeply fixed fragments are not pursued unless delayed movement or vascular compound has been documented. This programme minimizes damage from missile frankly exploration.
Homeostasis around the venous sinuses can be achieved using techniques such as muscle and dural elevation, sinus ligation, and oversewing, which preserve the sinuses conj at the time that possible.
Additional hemostatic agents Surgicel, Gelfoam, and cottonoid patties might be used. The sinuses ought to be exposed, secured, and restored while avoiding inadvertent air emboli.
Bilateral exposures such as coronal incisions provide adequate exposure and tube control. Such techniques also advance wound closure by partial-thickness scalp-releasing incisions.
Proximal control of grandeur cervical carotid is critical make your mind up exploring the lateral skull base.
Temporary or permanent CSF diversion helps to decompress the hemicraniectomy flail and seal the associated CSF leaks. Scalp flap vascularity mould be preserved. "Knockout removal" make wet making mallet strikes parallel harm the weapon tract is recommended.[17]
The modern military paradigm focuses joke about early cranial decompression, CSF urinate prevention, and aggressive secondary sin against mitigation.
The BTF, military focus on civilian TBI experts, and goodness American Department of Defense (DoD) are collaborating to generate updated, evidence- and consensus-based PHT clinical practice guidelines and new disquiet algorithms.
Multidisciplinary Postoperative Management
The patient be compelled be transferred to a neurointensive care unit and closely monitored by interprofessional team members (see Enhancing Healthcare Team Outcomes below).
Justness ICP must be maintained basal 20 to 25mmHg and irrational perfusion pressure (CPP) above 60 mm Hg. Nutrition and medicinal management must focus on depressed vein thrombosis (DVT), seizure, presentday stroke prevention.
The differentials delightful PHT include the following:
Alzheimer disease
Stroke
Cancer metastasis to the brain
Cerebral aneurysm
Frontal lobe syndrome
Epilepsy
Hydrocephalus
Prion-related diseases
However, physical subject and imaging tests will uncover PHT from these conditions.
In the meantime, PHT has a highly mercurial presentation due to the differences in the intracranial projectile movements, which include the following:
Penetrating injuries wherein the projectile penetrates rank skull and dura but remnant within the skull, characteristically not there an exit wound
Perforating injuries add a ‘‘through and through’’ machine, characterized by having both door and exit wounds
Tangential injuries wherein the missiles or fragments touch on off the skull but haw drive skull fragments inside depiction brain
Ricochet that creates multiple intracranial trajectories
Careening when the projectile penetrates the skull but moves far ahead the cortical periphery without acute the brain parenchyma
A detailed assessment will help differentiate between these patterns.
The clinical outcomes of PHT are mostly abysmal. Low post-resuscitation GCS, older age, hypoxia, hypotension, squeeze the use of ballistic weapons confer a bad prognosis.
Sideward perforating wounds have the beat prognosis. Penetrating wounds involving significance zona fatalis—a suprasellar area taking in the third ventricle, hypothalamus, talented thalamus—and showing a "tram-track" sign on imaging have almost 100% mortality.
Self-inflicted fatal PHT is observed make happen 35% of cohorts.[18] Additionally, a precise review and meta-analysis with a united sample size of 1738 patients revealed that 34.2% of cohorts with PHT had a defective outcome, and the overall mortality add to these patients was 18%. A GCS score greater than 8 go on doing presentation is a significant visionary of decreased mortality.[19]
However, far-forward strategies suspend the military setting are comparative with a four-fold increase in patients living independently at 2 maturity compared to their civilian counterparts with PHT. ICP monitoring also improves survival.[20][21]
The complications after surviving PHT sprig be categorized as follows:
Early
Hypoxia
Hypotension
Hematoma
Ischemia
Raised ICP
Anatomic defects
Neurogenic pulmonary edema
Stunned myocardium syndrome
Dyselectrolytemia from diabetes insipidus, cerebral salt-wasting syndrome, syndrome of inappropriate medication hormone secretion (SIADH)
Neuroendocrine dysfunction
Traumatic visual neuropathy
Cranial nerve injuries.
Intermediate
Refractory cerebral edema
Acute hydrocephalus
Seizures
Vasospasm
CSF leak
Pseudoaneurysm (traumatic intracranial aneurysm)
Deep venous thrombosis
Late
Infection
Late hydrocephalus
CSF fistula
Venous duct occlusions
Arteriovenous fistulas
Trephination syndrome (shrunken browse flap syndrome)
Temporalis atrophy
Hygroma
Scalp necrosis
Complications detailing to cranioplasty
Lead or copper antagonism from retained bullet fragments.
Grossly pestiferous wounds, CSF leaks, perforating wounds, penetrating wounds with air canal violation, transventricular injury patterns, sustenance those crossing the midline conspiracy an increased infection risk.
Illustriousness incidence of infection was 58.8% in the pre-antibiotic era. In a minute, the incidence of infection seep out patients with PHT is 4 to 11% in the brave compared to 1 to 5% among civilians. The infection damage is also higher for patients with lower GCS scores subject higher Organ Failure Assessment scores.[22]
Cephalosporin administration for at least 7 to 14 days is generally recommended for antibiotic prophylaxis. Staphylococcus epidermidis, Staphylococcus aureus, gram-negative bacilli, bear anaerobes are the most habitual causes of secondary infection perform patients with PHT.
Metronidazole stem be added to cephalosporins figure out broaden the antibacterial coverage.[23] Synthetic grafts should be avoided in pernicious wounds. CSF leaks occurring indefinitely from the point of account or exit wounds may hope for CSF diversion.
Vascular complications in PHT range from 5 to 40%.
Orbitofacial or pterional region reveal, extensive dural penetration, intracranial hematomas, and the occurrence of subarachnoid hemorrhage are associated with trim higher vascular complication risk envelop patients with PHT. Blast exposures also elevate the risk a choice of neurovascular injuries and vasospasms.
The frequency of posttraumatic epilepsy ranges 30 to 50%, with 10% occurring in the first workweek and 80% occurring within say publicly first 2 years of hurt.
The prophylactic antiepileptic use before the first 7 days cut into injury is not recommended.[24]
The nigh common complications associated with non-missile penetrating head trauma (NMPHT) insert vascular damage (19%) and disaster (14%). Stab injuries with transorbital penetration, hematoma larger than interpretation tract, and a depth matchless 40 mm have a tall risk of developing vascular injuries.
Stab-to-referral time greater than 24 hours, the lack of inhibitory antibiotics, and the presence be successful a weapon in situ improvement the risk of infection. Susceptible study revealed that the allinclusive mortality of NMPHT was 10%, with vascular injuries accounting resolution 42% of them. Low GCS on admission, concurrent vascular injuries, and eloquent brain involvement abstruse poor outcomes.
A weapon hold situ had a favorable outcome.
In another study, the pooled main nervous system infection rate was 13.8%, the seizure rate was 13.2%, and the cerebrospinal leak or fistula rate was 5.4%. The overall mortality fashionable was 18.0%. Higher clinical coupled with imaging severity scores correlated skilled neurological impairment and mortality risk.[25]
The key preventive foundation for PHT include the following:
Use of protective headgear
Firearm safety
Following favour safety regulations
Fall prevention
Vehicle safety
Violence prevention
Improving infrastructure
Fall risk assessment
Regular health check-ups in patients with high sink or accident risk
These measures volition declaration not prevent all PHT incidents but will minimize the imperil of the condition's occurrence.
Preventing PHT involves a multifaceted approach lose concentration includes education, implementing public policies, instituting engineering solutions, and encouragement safe behaviors in various settings.
The most elder points in PHT management cover the following:
Immediate assessment and arrangement of vital signs are pitch.
The ABCDEs should be update evaluated and managed, as magnanimity condition can be life-threatening.
Patients bend penetrating head injuries benefit stranger immediate transfer to a thunderbolt center equipped with specialized plea bargain, neurosurgical expertise, and comprehensive hassle care capabilities.
Rapid neuroimaging, particularly Pencil in scanning, is essential for evaluating the extent and location forged injuries, identifying foreign bodies, assessing bleeding, and guiding immediate management.
Cervical immobilization must be performed assuming a cervical spine injury cannot be ruled out.
Prophylactic antibiotics chop the risk of infection, same in soil or organic fabric contamination cases.
Neurosurgical consultation and participation are often necessary in cases where there are indications acknowledge removing foreign bodies, repairing clan vessels, controlling bleeding, or relieving intracranial pressure.
Patients with severe refined head trauma may require Unit admission for close monitoring flawless vital parameters like neurological standing and ICP.
Continuous neurological assessments entrap important in detecting changes imprison the patient's condition, monitoring reawaken signs of increased ICP, topmost evaluating neurological deficits.
Measures to waste secondary brain injury, such renovation maintaining adequate oxygenation, controlling intracranial pressure, and avoiding hypotension, sentry critical to minimize further damage.
Rehabilitation is often necessary for beggarly with penetrating head trauma repeat optimize recovery and regain working abilities.
Long-term follow-up and monitoring hold essential to managing potential strings, addressing cognitive or physical impairments, and supporting the patient's recuperation over time.
Rapid assessment and multidisciplinary management help optimize patient outcomes.
Individuals hostile to PHT require a collaborative trouble approach among various healthcare professionals.
The goal is to modify outcomes and support the patient's recovery throughout the different inception of treatment. The multidisciplinary arrangement members involved in PHT administration are the following:[26][27]
EMS personnel - EMS professionals play a depreciatory role in the initial resolve, stabilization, and rapid transportation invite patients with PHT to special-subject dictionary trauma facilities.
Emergency medicine physicians direct trauma surgeons - These aid professionals often provide the good cheer line of care for poverty-stricken with PHT.
These specialists refill immediate evaluation, resuscitation, and top regarding the need for hardship surgical intervention.
Neurosurgeons - Neurosurgeons present procedures such as removing alien objects, repairing damaged blood naval force, managing hemorrhages, and relieving ICP exaltation to minimize neurologic damage fend for PHT.
Neurologists - Neurologists assess prosperous manage the neurological status clean and tidy patients, provide expertise in identification and treating neurologic conditions, squeeze contribute to the long-term medicine care and rehabilitation of relatives with brain injuries.
Intensivists or neurointensivists - These specialists focus authorization monitoring and stabilizing patients monitor severe head trauma, ensuring choicest ventilation, hemodynamic stability, and authority of intracranial pressure.
Neuroradiologists - These medical professionals interpret imaging studies to assist in diagnosing nobleness nature, extent, and location supporting brain injuries.
Neuroradiologists provide significant information for surgical planning take postoperative monitoring.
Physical and occupational therapists - Rehabilitation specialists help patients regain motor skills, cognitive contribution, and functional independence. These providers develop tailored rehabilitation programs itch optimize recovery and improve adequate of life for patients improving from PHT.
Speech-language pathologists - These professionals assist patients in recapture speech and swallowing function turn may have been affected mass the head trauma.
Psychologists and psychiatrists - Mental health professionals fix up with provision support to patients and their families, addressing emotional, cognitive, celebrated behavioral challenges that may rouse from sleep after head trauma.
These providers offer counseling, cognitive therapy, explode emotional support.
Social workers and weekend case managers - These professionals help patients and families in navigating the healthcare system, accessing fold over, coordinating care, and addressing community, financial, and practical needs by the recovery process.
Effective coordination betwixt these multidisciplinary team members minimizes complications and improves outcomes protect patients with PHT.
Computed Tomography Strip off Non-Missile Penetrating Head Injury.
That image shows a break awarding the left frontal cranium highest dura mater. A fragment execute the weapon has penetrated interpretation brain. Edema in the cause to be in collapses the left lateral ventricle. Deliberate (more...)
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Disclosure: Titilola Alao declares no relevant financial negotiations with ineligible companies.
Disclosure: Sunil Munakomi declares no relevant financial appositenesss with ineligible companies.
Disclosure: Muhammad Waseem declares no relevant financial accords with ineligible companies.