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Chandrasekharan P, Lakshminrusimha S, Abman SH. When to say no to inhaled nitric oxide in neonates? Semin Fetal Neonatal Med 2021; 26:101200. [PMID: 33509680 DOI: 10.1016/j.siny.2021.101200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Inhaled nitric oxide (iNO) was approved for use in critically ill term and near-term neonates (>34 weeks gestational age) in 1999 for hypoxic respiratory failure (HRF) with evidence of pulmonary hypertension. In 2011 and 2014, the National Institutes of Health and American Academy of Pediatrics respectively recommended against the use of iNO in preterm infants <34 weeks. However, these guidelines were based on trials conducted with varying inclusion criteria and outcomes. Recent guidelines from the American Thoracic Society/American Heart Association, the Pediatric Pulmonary Hypertension Network (PPHNet) and European Pediatric Pulmonary Vascular Disease Network recommend the use of iNO in preterm neonates with HRF with confirmed pulmonary hypertension. This review discusses the available evidence for off-label use of iNO. Preterm infants with prolonged rupture of membranes and pulmonary hypoplasia appear to respond to iNO. Similarly, preterm infants with physiology of pulmonary hypertension with extrapulmonary right-to-left shunts may potentially have an oxygenation response to iNO. An overview of relative and absolute contraindications for iNO use in neonates is provided. Absolute contraindications to iNO use include a ductal dependent congenital heart disease where systemic circulation is supported by a right-to-left ductal shunt, severe left ventricular dysfunction and severe congenital methemoglobinemia. In preterm infants, we do not recommend the routine use of iNO in HRF due to parenchymal lung disease without pulmonary hypertension and prophylactic use to prevent bronchopulmonary dysplasia. Future randomized trials evaluating iNO in preterm infants with pulmonary hypertension and/or pulmonary hypoplasia are warranted. (233/250 words).
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Affiliation(s)
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California, Davis, USA.
| | - Steven H Abman
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, 80045, USA.
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2
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Molloy S, McVea S, Thompson A, Bourke T. In the child with pulmonary hypertension, does treatment with enteral sildenafil compared with a slow wean from nitric oxide alone prevent rebound pulmonary hypertension and allow for discontinuation of nitric oxide? Arch Dis Child 2020; 105:410-412. [PMID: 31780521 DOI: 10.1136/archdischild-2019-318233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/09/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Seana Molloy
- Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Steven McVea
- Paediatric Intensive Care, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Andrew Thompson
- Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Thomas Bourke
- School of medicine, dentistry and biomedical sciences, Queens University, Belfast, UK
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3
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Centorrino R, Shankar-Aguilera S, Foligno S, De Luca D. Life-Threatening Extreme Methemoglobinemia during Standard Dose Nitric Oxide Therapy. Neonatology 2019; 116:295-298. [PMID: 31454813 DOI: 10.1159/000501462] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/12/2019] [Indexed: 11/19/2022]
Abstract
We report the first case of life-threatening extreme neonatal-acquired methemoglobinemia that occurred during inhaled nitric oxide (iNO) at the standard 20 ppm dose in a neonate with early onset sepsis and suprasystemic pulmonary hypertension. Life-threatening methemoglobinemia has been efficaciously treated with methylene blue and ascorbic acid, while stopping iNO and starting iloprost and sildenafil. The patient was subjected to various tests (including gene sequencing and hemoglobin electrophoresis) and did not have any known genetic cause or predisposition for methemoglobinemia. Neuroimaging and the 2-year clinical follow-up were completely normal.
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Affiliation(s)
- Roberta Centorrino
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Center, South Paris University Hospitals, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France,
| | - Shivani Shankar-Aguilera
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Center, South Paris University Hospitals, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Silvia Foligno
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Center, South Paris University Hospitals, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Center, South Paris University Hospitals, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,Physiopathology and Therapeutic Innovation Unit - INSERM U999, South Paris-Saclay University, Paris, France
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Abstract
Methaemoglobinaemia is a rare but potentially dangerous haemoglobinopathy that is often underdiagnosed. It is one of the causes for unexplained cyanosis with dark-coloured blood, especially in the absence of cardiac or pulmonary pathology. Not uncommonly so, it is an incidental perioperative finding in cases of dark-coloured blood not improving with oxygen in apparently acyanotic patients. The present case report is of a child with deaf-mutism posted for cochlear implant surgery who presented with 'chocolate-coloured blood' in the surgical field, despite blood gas analysis showing a normal partial pressure of oxygen.
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Affiliation(s)
- Swapnil Verma
- Department of Anaesthesia, Apollo Hospital Jubilee Hills, Hyderabad, Telangana, India
| | - A K Sathpathy
- Department of Anaesthesia, Apollo Hospital Jubilee Hills, Hyderabad, Telangana, India
| | - U Srinivas
- Department of Anaesthesia, Apollo Hospital Jubilee Hills, Hyderabad, Telangana, India
| | - Sanath Reddy
- Department of Anaesthesia, Apollo Hospital Jubilee Hills, Hyderabad, Telangana, India
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Nilsson KF, Sandin J, Gustafsson LE, Frithiof R. The novel nitric oxide donor PDNO attenuates ovine ischemia-reperfusion induced renal failure. Intensive Care Med Exp 2017; 5:29. [PMID: 28600797 PMCID: PMC5466578 DOI: 10.1186/s40635-017-0143-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/26/2017] [Indexed: 01/18/2023] Open
Abstract
Background Renal ischemia-reperfusion injury is a common cause of acute kidney injury in intensive care and surgery. Recently, novel organic mononitrites of 1,2-propanediol (PDNO) were synthesized and shown to rapidly and controllably deploy nitric oxide in the circulation when administered intravenously. We hypothesized that intravenous infusion of PDNO during renal ischemia reperfusion would improve post-ischemic renal function and microcirculation. Methods Sixteen sheep were anesthetized, mechanically ventilated, and surgically instrumented. The left renal artery was clamped for 90 min, and the effects of ischemia were studied for a total of 8 h. Fifteen minutes prior to the release of the clamp, intravenous infusions of PDNO (n = 8) or vehicle (1,2 propanediol + inorganic nitrite, n = 8) were initiated (180 nmol/kg/min for 30 min, thereafter 60 nmol/kg/min for the remainder of the experiment). Results Renal artery blood flow, cortical and medullary perfusion, and diuresis and creatinine clearance decreased in the left kidney post ischemia. However, in the sheep treated with PDNO, diuresis and creatinine clearance in the left kidney were significantly higher post ischemia compared to vehicle-treated animals (1.7 ± 0.5 vs 0.7 ± 0.3 ml/kg/h, p = 0.04 and 7.5 ± 2.1 vs 1.7 ± 0.6 ml/min, p = 0.02, respectively). Left renal medullary perfusion and oxygen uptake were higher in the PDNO group (73 ± 9 vs 37 ± 5% of baseline, p = 0.004 and 2.6 ± 0.4 vs 1.6 ± 0.3 ml/min, p = 0.02, respectively). PDNO significantly increased renal oxygen consumption and reduced the oxygen utilization for sodium reabsorption (p = 0.03 for both). Mean arterial blood pressure was significantly reduced by PDNO (83 ± 3 vs 94 ± 3 mmHg, p = 0.02) but was still within normal limits. Total renal blood flow was not affected, and there were no signs of increased blood methemoglobin concentrations or tachyphylaxis. Conclusions The novel nitric oxide donor PDNO improved renal function after ischemia. PDNO also prevented the persistent reduction in medullary perfusion during reperfusion and improved renal oxygen utilization without severe side effects.
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Affiliation(s)
- Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - John Sandin
- Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lars E Gustafsson
- Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Robert Frithiof
- Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden. .,Department of Surgical Sciences, Section of Anesthesia and Intensive Care, Uppsala University, Uppsala, Sweden.
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Fukazawa K, Lang JD. Role of nitric oxide in liver transplantation: Should it be routinely used? World J Hepatol 2016; 8:1489-1496. [PMID: 28008339 PMCID: PMC5143429 DOI: 10.4254/wjh.v8.i34.1489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 08/06/2016] [Accepted: 10/18/2016] [Indexed: 02/06/2023] Open
Abstract
Ischemia-reperfusion injury (IRI) continues to be a major contributor to graft dysfunction, thus supporting the need for therapeutic strategies focused on minimizing organ damage especially with growing numbers of extended criteria grafts being utilized which are more vulnerable to cold and warm ischemia. Nitric oxide (NO·) is highly reactive gaseous molecule found in air and regarded as a pollutant. Not surprising, it is extremely bioactive, and has been demonstrated to play major roles in vascular homeostasis, neurotransmission, and host defense inflammatory reactions. Under conditions of ischemia, NO· has consistently been demonstrated to enhance microcirculatory vasorelaxation and mitigate pro-inflammatory responses, making it an excellent strategy for patients undergoing organ transplantation. Clinical studies designed to test this hypothesis have yielded very promising results that includes reduced hepatocellular injury and enhanced graft recovery without any identifiable complications. By what means NO· facilitates extra-pulmonary actions is up for debate and speculation. The general premise is that they are NO· containing intermediates in the circulation, that ultimately mediate either direct or indirect effects. A plethora of data exists explaining how NO·-containing intermediate molecules form in the plasma as S-nitrosothiols (e.g., S-nitrosoalbumin), whereas other compelling data suggest nitrite to be a protective mediator. In this article, we discuss the use of inhaled NO· as a way to protect the donor liver graft against IRI in patients undergoing liver transplantation.
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Sokol GM, Konduri GG, Van Meurs KP. Inhaled nitric oxide therapy for pulmonary disorders of the term and preterm infant. Semin Perinatol 2016; 40:356-369. [PMID: 27480246 PMCID: PMC5065760 DOI: 10.1053/j.semperi.2016.05.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The 21st century began with the FDA approval of inhaled nitric oxide therapy for the treatment of neonatal hypoxic respiratory failure associated with pulmonary hypertension in recognition of the 2 randomized clinical trials demostrating a significant reduction in the need for extracorporeal support in the term and near-term infant. Inhaled nitric oxide is one of only a few therapeutic agents approved for use through clinical investigations primarily in the neonate. This article provides an overview of the pertinent biology and chemistry of nitric oxide, discusses potential toxicities, and reviews the results of pertinent clinical investigations and large randomized clinical trials including neurodevelopmental follow-up in term and preterm neonates. The clinical investigations conducted by the Eunice Kennedy Shriver NICHD Neonatal Research Network will be discussed and placed in context with other pertinent clinical investigations exploring the efficacy of inhaled nitric oxide therapy in neonatal hypoxic respiratory failure.
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Affiliation(s)
- Gregory M. Sokol
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46254
| | - G. Ganesh Konduri
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304
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Namachivayam P, Theilen U, Butt WW, Cooper SM, Penny DJ, Shekerdemian LS. Sildenafil Prevents Rebound Pulmonary Hypertension after Withdrawal of Nitric Oxide in Children. Am J Respir Crit Care Med 2006; 174:1042-7. [PMID: 16917115 DOI: 10.1164/rccm.200605-694oc] [Citation(s) in RCA: 138] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Rebound pulmonary hypertension (PHT) can complicate the weaning of nitric oxide (NO), and is in part related to transient depletion of intrinsic cyclic guanosine monophosphate. Rebound is characterized by increased pulmonary arterial (PA) pressure, cardiopulmonary instability, and in some cases, the need to continue NO beyond the intended period of use. There is anecdotal evidence that sildenafil, a phosphodiesterase-5 inhibitor, may prevent recurrence of rebound. OBJECTIVES We investigated the role of sildenafil in preventing rebound (an increase in PA pressure of 20% or greater, or failure to discontinue NO) in patients in whom previous attempts had not been made to wean from NO. METHODS Thirty ventilated infants and children, receiving 10 ppm or greater inhaled NO, were randomized to receive 0.4 mg/kg of sildenafil, or placebo, 1 h before discontinuing NO. Twenty-nine patients completed the study. MEASUREMENTS PA pressures and blood gases were measured before the study drug, and 1 and 4 h after stopping NO. MAIN RESULTS Rebound occurred in 10 of 14 placebo patients, and 0 of 15 sildenafil patients (p < 0.001). PA pressure increased by 25% (14-67) in placebo patients, and by 1%(-9-5) in sildenafil patients (p < 0.001). Four placebo patients could not be weaned from NO due to severe cardiovascular instability, whereas all sildenafil patients were weaned (p = 0.042). Duration of ventilation after study was 98.0 (47.0-223.5) h for placebo patients and 28.2 (15.7-54.6) h for sildenafil patients (p = 0.024). CONCLUSION A single dose of sildenafil prevented rebound after withdrawal of NO, and reduced the duration of mechanical ventilation. Prophylaxis with sildenafil should be considered when weaning patients from inhaled NO.
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Abstract
This article reviews the various cardiovascular drugs for newborns, including antiarrhythmics, antihypertensives, inotropes, and pulmonary vasodilators. Antiarrhythmic drugs are classified according to their mechanisms of action, such as effects on ion channels, duration of repolarization, and receptor interaction, which help with understanding the effects of individual antiarrhythmic drugs and selection of drugs for specific arrhythmias. Drug treatment for hypertension should start with a single drug from one of the following classes: ACE inhibitors, angiotensin-receptor antagonists, beta-receptor antagonists, calcium channel blockers, or diuretics. The inotropic drug should be selected according to its specific pharmacologic properties and the specific cardiovascular abnormality to be corrected. An effective pulmonary vasodilator must dilate the pulmonary vasculature more than the systemic vasculature.
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Affiliation(s)
- Robert M Ward
- Division of Neonatology, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
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10
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Travadi JN, Patole SK. Phosphodiesterase inhibitors for persistent pulmonary hypertension of the newborn: a review. Pediatr Pulmonol 2003; 36:529-35. [PMID: 14618646 DOI: 10.1002/ppul.10389] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a complex syndrome with multiple causes, with an incidence of 0.43-6.8/1,000 live births and a mortality of 10-20%. Survivors have high morbidity in the forms of neurodevelopmental and audiological impairment, cognitive delays, hearing loss, and a high rate of rehospitalization. The optimal approach to the management of PPHN remains controversial. Inhaled nitric oxide (iNO) is currently regarded as the gold standard therapy, but with as many as 30% of cases failing to respond, has not proven to be the single magic bullet. Given the complex pathophysiology of the disease, any such magic bullet is unlikely. A number of recent studies have suggested a role for specific phosphodiesterase (PDE) inhibitors in the management of PPHN. Sildenafil, a specific PDE5 inhibitor, appears the most promising of such agents. We aim to review the current status and limitations of iNO and the potential of PDE inhibitors in the management of PPHN. The reasons why caution is warranted before specific PDE5 inhibitors like sildenafil are labelled as potential magic bullets for PPHN will be discussed. The need for randomized-controlled trials to determine the safety, efficacy, and long-term outcome following treatment with sildenafil in PPHN is emphasized.
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Affiliation(s)
- J N Travadi
- Department of Neonatal Paediatrics, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia
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Salguero KL, Cummings JJ. Inhaled nitric oxide and methemoglobin in full-term infants with persistent pulmonary hypertension of the newborn. Pulm Pharmacol Ther 2002; 15:1-5. [PMID: 11969358 DOI: 10.1006/pupt.2001.0311] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Inhaled nitric oxide (iNO), a potent pulmonary vasodilator, has become a mainstay therapy for neonates with persistent pulmonary hypertension of the newborn (PPHN). However, it also oxidizes hemoglobin to methemoglobin (metHgb), thereby reducing the delivery of oxygen to tissues. Studies have suggested that elevated levels of metHgb may be avoided by limiting iNO concentration to less than 40 parts per million (ppm). However, the relationship between iNO exposure and elevated levels of metHgb (greater than 4%) has not been examined. Therefore, we studied this relationship in full term newborns with PPHN. We reviewed the charts of twenty-eight neonates with a diagnosis of PPHN admitted to our Intensive Care Nursery between 1/92 and 10/97. Our retrospective analysis demonstrated that: (1) high metHgb levels can occur with exposure to low iNO concentration (three of eight newborns with maximum metHgb levels >4% had been exposed to no more than 40 ppm of iNO concentration); and (2) cumulative iNO ( summation operatoriNO) exposure was the best predictor of elevated metHgb levels (seven of nine newborns receiving summation operatoriNO>2000 ppm x hour had maximum metHgb levels >4%).
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Affiliation(s)
- Karla L Salguero
- Department of Physiology and BioPhysics, Center for the Developmental Biology of the Lung, State University of New York at Buffalo, 14214, USA
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Taylor MB, Christian KG, Patel N, Churchwell KB. Methemoglobinemia: Toxicity of inhaled nitric oxide therapy. Pediatr Crit Care Med 2001; 2:99-101. [PMID: 12797897 DOI: 10.1097/00130478-200101000-00019] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Elevation in methemoglobin is a known toxicity of inhaled nitric oxide (NO) therapy. This article describes two significant episodes of methemoglobinemia. These cases illustrate the probable cause and the treatment strategies for the potential for delivery of high concentrations of NO, resulting in methemoglobinemia with moderate and even low-dose delivered NO. We propose mechanisms for this occurrence and means of prevention.
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Affiliation(s)
- M B Taylor
- Division of Pediatric Critical Care and Anesthesia (Drs. Taylor, Patel, and Churchwell) and the Department of Cardiac and Thoracic Surgery (Dr. Christian), Vanderbilt University Medical Center, Nashville, TN
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13
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Finan A, Keenan P, Donovan FO, Mayne P, Murphy J. Methaemoglobinaemia associated with sodium nitrite in three siblings. BMJ (CLINICAL RESEARCH ED.) 1998; 317:1138-9. [PMID: 9784456 PMCID: PMC1114113 DOI: 10.1136/bmj.317.7166.1138] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- A Finan
- Children's Hospital, Dublin 1.
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