Dexmedetomidine as a Perioperative Adjunct in Valvular Cardiac Surgery

Dexmedetomidine as a Perioperative Adjunct in Valvular Cardiac Surgery | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Dexmedetomidine as a Perioperative Adjunct in Valvular Cardiac Surgery View ORCID Profile Sanjeeta Umbarkar , View ORCID Profile Jalaram Harshappan , View ORCID Profile Parimal Pimpalkhute , View ORCID Profile Pooja Pimpalkhute , View ORCID Profile Renu Upadhyay , View ORCID Profile Juhi Kacha doi: https://doi.org/10.1101/2025.09.04.25334916 Sanjeeta Umbarkar 1 Head of Department of Cardiac Anaesthesia, Seth GS Medical College and KEM Hospital , Mumbai, India MD Anesthesia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sanjeeta Umbarkar For correspondence: sanjeeta69{at}yahoo.com Jalaram Harshappan 2 Department of Cardiac Anaesthesia, Seth GS Medical College and KEM Hospital , Mumbai, India DNB Anesthesia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jalaram Harshappan Parimal Pimpalkhute 2 Department of Cardiac Anaesthesia, Seth GS Medical College and KEM Hospital , Mumbai, India DM Cardiac Anesthesia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Parimal Pimpalkhute Pooja Pimpalkhute 2 Department of Cardiac Anaesthesia, Seth GS Medical College and KEM Hospital , Mumbai, India DM Cardiac Anesthesia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Pooja Pimpalkhute Renu Upadhyay DM Cardiac Anesthesia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Renu Upadhyay Juhi Kacha 3 Department of Anesthesia, AIIMS Rishikesh DNB Anesthesia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Juhi Kacha Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Background Valvular heart surgery is associated with considerable perioperative risks including hemodynamic instability, arrhythmias, renal dysfunction and prolonged ICU stay. Dexmedetomidine a selective α2-adrenoceptor agonist, provides sedation and sympatholysis and has been investigated as a cardioprotective adjunct. Objectives To evaluate the effects of dexmedetomidine on intraoperative hemodynamic stability and postoperative outcomes in adult patients undergoing valvular replacement surgery. Methods In this retrospective study, 154 patients who underwent valvular surgery under cardiopulmonary bypass between January 2022 and June 2023 were analyzed. Patients were divided into Group C (control, n=77) and Group D (dexmedetomidine, n=77). Group D received a continuous infusion of dexmedetomidine (0.5 μg/kg/hr) from induction until the end of surgery. Hemodynamic and depth of sedation parameters (HR, MAP, CVP, NIRS, entropy) were measured at predefined intraoperative time points. Postoperative outcomes included time of extubation, atrial fibrillation (AF), acute kidney injury (AKI), Type 2 neurological injury, reintubation, reoperation, ICU readmission, ICU length of stay (LOS), and 30-day mortality. Results Baseline demographics were similar between groups. Group D exhibited significantly lower HR and MAP at post-induction, sternotomy, and pericardiotomy ( p <0.001 for HR; p <0.05 for MAP). ICU LOS was significantly shorter in Group D (7.23 ± 2.96 vs. 8.68 ± 3.88 days, p =0.010). Time to extubation was also significantly reduced in Group D (74.78 ± 215.30 vs. 192.10 ± 352.61 hours, p =0.014). AF (2.6% vs. 13.0%, p =0.031), AKI (2.6% vs. 14.3%, p =0.017), reintubation (0% vs. 10.4%, p =0.006), reoperation (2.6% vs. 13.0%, p =0.031), Type 1 neuro injury (2.6% vs. 13.0%, p =0.031), and ICU readmission (2.6% vs. 13.0%, p =0.031) were all significantly reduced in Group D. Thirty-day mortality was also lower (2.6% vs. 14.3%, p =0.021). Conclusion Dexmedetomidine use during valvular cardiac surgery was associated with improved intraoperative hemodynamic stability, reduced postoperative complications including atrial fibrillation, acute kidney injury, and neurological injury, shorter ICU stay, faster extubation, and lower 30-day mortality. These findings suggest that dexmedetomidine may provide comprehensive organ protection in high-risk surgical patients. Confirmation in larger multicenter randomized controlled trials is required Introduction Valvular heart disease continues to be a major public health challenge, particularly in low- and middle-income countries (LMICs) in India where rheumatic heart disease contributes significantly to disease burden ( 1 ) . Globally millions undergo cardiac surgery annually and patients with valvular pathologies face higher perioperative risks than those undergoing coronary artery bypass grafting ( 2 ) . The physiological stresses of cardiopulmonary bypass (CPB), including systemic inflammation, ischemia-reperfusion injury and resultant sympathetic activation exacerbate these risks ( 3 ) . Hemodynamic fluctuations perioperatively, arrhythmias, renal impairment and neurological injury remain frequent complications despite advances in surgical and anesthetic techniques ( 4 ) . Dexmedetomidine a highly selective α2-adrenoceptor agonist has emerged as a valuable adjunct in anesthesia and intensive care. It provides cooperative sedation without respiratory depression and exerts sympatholytic, anxiolytic and analgesic effects ( 5 ) . Importantly its pharmacological actions extend beyond sedation: it causes reduction in catecholamine release, stabilizes heart rate and blood pressure, improves myocardial oxygen balance and modulates inflammatory cytokines ( 6 , 7 ) . These properties make dexmedetomidine particularly attractive in the setting of cardiac surgery where hemodynamic stability and organ protection are critical in comparison to other types of surgeries. Multiple studies have explored the role of dexmedetomidine in perioperative care. Systematic reviews and meta-analyses have demonstrated reductions in perioperative tachycardia, arrhythmia, delirium, and ICU stay ( 8 , 10 ) . Trials in coronary artery bypass grafting and valve surgery suggest improved outcomes with dexmedetomidine, though evidence remains diverse ( 11 , 12 ) . Cohort studies focusing on valve surgery populations specifically report reduced complications and shorter CICU length of stay ( 13 ) . However gaps persist regarding consistent benefits on mortality and the risk of adverse effects such as bradycardia or hypotension which are known effects of the drug ( 14 ) . Given the particular vulnerability of patients undergoing valvular cardiac surgery, further evaluation of dexmedetomidine’s impact in this specific subgroup is essential. As the benefits which are being offered by the drug are fascinating notwithstanding the supposed adverse effects of the medication. This retrospective study was therefore undertaken to assess the effects of perioperative dexmedetomidine on intraoperative hemodynamics, postoperative complications, and ICU stay in adult patients undergoing valvular replacement surgery at a tertiary care center. Methods Study Design and Ethics This was a retrospective observational study conducted at the Department of Cardiac Anaesthesia, Seth GS Medical College and KEM Hospital, Mumbai. Data were collected from institutional records between January 2022 and June 2023. Ethical approval was obtained from the Institutional Ethics Committee. Study Population Inclusion criteria Adults aged 18–70 years undergoing valvular cardiac surgery under CPB. Exclusion criteria Preoperative opioid use, conduction disorders, oxygen therapy prior to inclusion, LVEF <40%, BMI ≥35 kg/m², shock, recent myocardial ischemia, adrenal insufficiency/on long term corticosteroid therapy, long term non-invasive ventilation, antecedent or active drug addiction, contraindications to dexmedetomidine or other anesthetic drugs, severe hepatic insufficiency, neurological disease, pregnancy/parturient or feeding mothers, pre-existing cognitive dysfunction, Person deprived of liberty by an administrative or judicial decision or person placed under judicial protection / under guardianship or guardianship andPatient participating in another drug trial or having participated in another drug trial within 1 month before randomization Group Allocation Group C (Control, n=77): Standard anesthesia without dexmedetomidine. Group D (Dexmedetomidine, n=77): Received IV dexmedetomidine infusion (0.5 μg/kg/hr) after induction until the end of surgery. Anesthetic Management The patients on arrival to the operation theatre were connected to the monitor and baseline parameters (Heart rate, Spo2, Non-invasive blood pressure, Entropy and Near-infrared Spectroscopy) were recorded. Premedication with Inj. midazolam 0.02 mg/kg iv, Inj. Fentanyl 5-8ug/kg iv was given. Pre-oxygenation with 100% oxygen done for 3mins following which Inj. Dexmedetomidine was started as IV infusion at 0.5 ug/kg/hr for group D. For patients included in group C everything apart from the dexmedetomidine infusion was carried out in a similar fashion, which included supplemental fentanyl boluses for both groups at times where there was a decrease in depth of anesthesia. Baseline neuromuscular monitoring baseline for Train of Four was obtained after induction carried out using Inj. Etomidate 0.3mg/kg IV followed by muscle relaxant Inj. Rocuronium 1mg/kg. Anaesthesia was maintained with intermittent Inj. Rocuronium 0.1-0.15mg/kg, an infusion of dexmedetomidine at the rate of 0.5 μg/Kg/hour for group D and isoflurane. The infusion of dexmedetomidine was discontinued at the end of surgery. Cardiopulmonary Bypass and Monitoring All patients underwent CPB using standard institutional protocols with moderate hypothermia (∼28 °C). CPB flow rates were maintained at 2.4 L/min/m², with mean arterial pressure (MAP) targeted at 60–70 mmHg. Arterial blood gases were monitored hourly. Hemodynamic monitoring included invasive arterial pressure, central venous pressure (CVP), entropy, and near-infrared spectroscopy (NIRS) for cerebral oxygenation. Heart rate (HR), MAP, CVP, entropy, and NIRS were recorded at predefined time points: baseline, post-induction, sternotomy, pericardiotomy, 5 minutes after protamine administration, and at the end of surgery. Postoperative Care All patients were managed in the cardiac surgical ICU. Extubation, inotrope use and reintubation were guided by standard institutional protocols. Postoperative outcomes assessed included time of extubation, reintubation, reoperation, atrial fibrillation (AF), acute kidney injury (AKI, KDIGO criteria), type 1 neurological injury (stroke/TIA), ICU readmission, ICU length of stay (LOS), and 30-day mortality. Outcomes Primary outcomes: Intraoperative hemodynamic stability and entropy. Secondary outcomes: Postoperative complications (AF, AKI, reintubation, reoperation, neurological injury, mortality) and ICU LOS. Statistical Analysis Continuous variables were expressed as mean ± SD and compared using Student’s t-test. Categorical variables were expressed as frequencies and percentages and compared using Chi-square or Fisher’s exact test, as appropriate. P <0.05 was considered statistically significant. Analyses were performed using SPSS v22. Results Baseline Characteristics View this table: View inline View popup Download powerpoint Table 1. Baseline Demographic and Clinical Characteristics Baseline demographics were comparable between groups. Intraoperative Hemodynamics Group D demonstrated significantly lower HR at post-induction, sternotomy, and pericardiotomy compared to Group C ( Table 2 , Figure 1 ). Similarly, MAP was significantly lower in Group D at post-induction, sternotomy, and pericardiotomy, while transiently higher after protamine ( Table 2 , Figure 2 ). CVP and entropy were broadly comparable, while NIRS values were not significantly different ( Table 2 ). View this table: View inline View popup Table 2. Intraoperative Hemodynamic Parameters Download figure Open in new tab Figure 1. Intraoperative HR (mean ± SD) at six predefined time points. Download figure Open in new tab Figure 2. Intraoperative MAP (mean ± SD) at six predefined time points. Postoperative Outcomes Group D patients had significantly shorter time to extubation, ICU LOS ( Table 3 , Figure 3 ) and fewer postoperative complications, including atrial fibrillation, AKI, reintubation, and reoperation ( Table 3 , Figure 4A and 4B ). View this table: View inline View popup Download powerpoint Table 3. Postoperative Outcomes Download figure Open in new tab Figure 3. ICU length of stay (mean ± SD) in Group C vs Group D. Download figure Open in new tab Figure 4. Postoperative outcomes. (A) Incidence (%) of postoperative complications including reintubation, reoperation, atrial fibrillation (AF), acute kidney injury (AKI), Type 1 neurological injury, ICU readmission, and 30-day mortality. (B) Time to extubation (mean ± SD, hours). Group D (dexmedetomidine) showed consistently lower complication rates and significantly faster extubation compared with Group C (control) Discussion This study demonstrates that perioperative dexmedetomidine use in valvular cardiac surgery was associated with improved intraoperative hemodynamic stability, reduced postoperative complications, shorter ICU stay, faster extubation, and lower short-term mortality. Hemodynamic stability Dexmedetomidine significantly lowered HR and MAP at surgical stress points ( Figures 1 – 2 ), consistent with its sympatholytic properties ( 5 ) . These findings align with prior trials showing attenuation of perioperative tachycardia and MAP fluctuations ( 7 , 8 ) . Organ protection Group D had lower rates of AF, AKI, and Type 1 neuro injury ( Figure 4A ). The reduction in neurological injury is an important finding, consistent with experimental and clinical data suggesting dexmedetomidine may attenuate cerebral ischemia–reperfusion injury, reduce excitotoxicity, and promote neuroprotection ( 7 , 16 , 18 ) . These protective effects, together with the observed antiarrhythmic ( 12 ) and renoprotective ( 9 , 15 ) benefits strengthen the case for dexmedetomidine as a multimodal organ-protective agent. Recovery ICU LOS was significantly shorter in Group D ( Figure 3 ), aligning with previous valve cohorts ( 13 ) and meta-analyses ( 8 , 10 ) . Time to extubation was also significantly reduced in the dexmedetomidine group ( Figure 4B ). Faster extubation likely reflects a combination of lighter, cooperative sedation, opioid-sparing effects, and improved hemodynamic stability. Earlier weaning from mechanical ventilation is clinically important as it reduces ventilator-associated complications and may contribute to lower ICU stay and overall morbidity. Comparison with literature Our findings corroborate Ji et al. ( 17 ) and Fan et al. ( 13 ) , who reported reduced arrhythmias, ICU LOS, and mortality with dexmedetomidine. The extubation benefit is also in line with studies in cardiac and non-cardiac populations where dexmedetomidine facilitated early recovery from anesthesia ( 6 , 11 ) . The observed reduction in neurological injury parallels experimental evidence and smaller clinical trials suggesting neurocognitive benefits ( 16 , 18 ) . Nonetheless, mortality benefits remain debated ( 2 , 14 ) . Strengths & limitations Strengths include a homogenous valvular cohort, comprehensive intraoperative monitoring, and robust outcome analysis. Limitations include retrospective design, single-center scope, and modest sample size. Clinical implications Dexmedetomidine may be integrated into perioperative protocols for valvular surgery, particularly in LMICs where reducing ICU stay, accelerating extubation, lowering complication rates, and providing potential neuroprotection can conserve critical resources. Conclusion Dexmedetomidine use during valvular cardiac surgery was associated with improved intraoperative hemodynamic stability, reduced postoperative complications including atrial fibrillation, acute kidney injury, and neurological injury, shorter ICU stay, faster extubation, and lower 30-day mortality. These findings suggest that dexmedetomidine may provide comprehensive organ protection in high-risk surgical patients. Confirmation in larger multicenter randomized controlled trials is required Ethics Statement This study was approved by the Institutional Ethics Committee of Seth GS Medical College and KEM Hospital, Mumbai (Project No: EC/OA-46/2024) The requirement for individual patient consent was waived due to the retrospective nature of the study. Funding Statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest Statement The authors declare that they have no competing interests. Author Contributions Dr. Sanjeeta Umbarkar: Conceptualization, methodology Data interpretation, manuscript review, critical revision Dr. Jalaram Harshappan: Data collection, statistical analysis, manuscript drafting. Dr. Parimal Pimpalkhute, Dr. Pooja Pimpalkhute, Dr. Renu Upadhyay, Dr. Juhi Kacha: Approved the final manuscript. Data Availability Statement The anonymized dataset analyzed during the current study is available from the corresponding author on reasonable request, in accordance with institutional and ethical guidelines. Acknowledgements The authors thank the staff of the Department of Cardiac Anaesthesia, Seth GS Medical College and KEM Hospital, Mumbai, for their support in data collection Footnotes Declarations: Ethics Approval: This study was approved by the Institutional Ethics Committee of Seth GS Medical College and KEM Hospital, Mumbai (Project No:EC/OA-46-2024) Funding: None. Conflicts of Interest: None declared. Data Availability: The anonymized dataset is available from the corresponding author on reasonable request. References 1. ↵ Naaz S , Ozair E . Dexmedetomidine in current anaesthesia practice—a review . J Clin Diagn Res . 2014 ; 8 ( 10 ): GE01 – 4 . OpenUrl 2. ↵ Leino K , Hynynen M , Jalonen J , Salmenperä M , Scheinin H , Aantaa R . 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J Cardiothorac Vasc Anesth . 2022 ; 36 ( 10 ): 3075 – 84 . OpenUrl 28. International Society of Cardiovascular Anesthesiologists . Perioperative care recommendations with α2 agonists . J Cardiothorac Vasc Anesth . 2022 ; 36 ( Suppl 1 ): S1 – S15 . OpenUrl View the discussion thread. Back to top Previous Next Posted September 07, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Dexmedetomidine as a Perioperative Adjunct in Valvular Cardiac Surgery Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. 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Share Dexmedetomidine as a Perioperative Adjunct in Valvular Cardiac Surgery Sanjeeta Umbarkar , Jalaram Harshappan , Parimal Pimpalkhute , Pooja Pimpalkhute , Renu Upadhyay , Juhi Kacha medRxiv 2025.09.04.25334916; doi: https://doi.org/10.1101/2025.09.04.25334916 Share This Article: Copy Citation Tools Dexmedetomidine as a Perioperative Adjunct in Valvular Cardiac Surgery Sanjeeta Umbarkar , Jalaram Harshappan , Parimal Pimpalkhute , Pooja Pimpalkhute , Renu Upadhyay , Juhi Kacha medRxiv 2025.09.04.25334916; doi: https://doi.org/10.1101/2025.09.04.25334916 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Anesthesia Subject Areas All Articles Addiction Medicine (569) Allergy and Immunology (863) Anesthesia (300) Cardiovascular Medicine (4441) Dentistry and Oral Medicine (444) Dermatology (383) Emergency Medicine (609) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1510) Epidemiology (15230) Forensic Medicine (30) Gastroenterology (1126) Genetic and Genomic Medicine (6608) Geriatric Medicine (668) Health Economics (998) Health Informatics (4542) Health Policy (1369) Health Systems and Quality Improvement (1613) Hematology (543) HIV/AIDS (1266) Infectious Diseases (except HIV/AIDS) (15923) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (147) Nephrology (668) Neurology (6607) Nursing (346) Nutrition (999) Obstetrics and Gynecology (1146) Occupational and Environmental Health (957) Oncology (3335) Ophthalmology (974) Orthopedics (369) Otolaryngology (420) Pain Medicine (436) Palliative Medicine (130) Pathology (663) Pediatrics (1693) Pharmacology and Therapeutics (692) Primary Care Research (711) Psychiatry and Clinical Psychology (5448) Public and Global Health (9237) Radiology and Imaging (2201) Rehabilitation Medicine and Physical Therapy (1370) Respiratory Medicine (1196) Rheumatology (596) Sexual and Reproductive Health (714) Sports Medicine (530) Surgery (712) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a0182a2c481058d3',t:'MTc3OTc1MDExNQ=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();