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Sheasby J, Krais S, Do M, Hall A, Pace H, Myers DP, George TJ. An Interprofessional Approach to Mobilizing Patients With COVID-19 Receiving Extracorporeal Membrane Oxygenation. AACN Adv Crit Care 2022; 33:262-273. [PMID: 36067264 DOI: 10.4037/aacnacc2022293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To assess survival outcomes with the intervention of an interprofessional mobilization program for patients with COVID-19 who were receiving venovenous extracorporeal membrane oxygenation (VV-ECMO). DESIGN Preintervention and postintervention retrospective cohort study. METHODS Survival outcomes of nonmobilized, adult patients (n = 16) with COVID-19 who were receiving VV-ECMO (May 2020 through December 2020) were compared with those of 26 patients who received a mobility care plan (January 2021 through November 2021). In the preintervention group, full sedation and paralysis were used. In the postintervention group, an early mobilization strategy involving interprofessional collaboration was introduced. RESULTS The postintervention group had improved survival (73.1% vs 43.8%; P < .04); fewer days of receiving paralytics, fentanyl, and midazolam (P < .01 for all); but more days of dexmedetomidine, morphine, and ketamine administration (P < .01 for all). Concomitantly, more patients in the postintervention cohort received oral or transdermal analgesics, oral anxiolytics, and oral antipsychotics (P < .01 for all), and also required more VV-ECMO cannula adjustments (P = .03). CONCLUSION Early mobilization of patients with COVID-19 who were receiving VV-ECMO improved survival rates but led to more cannula adjustments.
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Affiliation(s)
- Jenelle Sheasby
- Jenelle Sheasby is ECMO Coordinator, Baylor Scott & White The Heart Hospital, 1100 Allied Drive, Plano, TX 75093
| | - Suzanne Krais
- Suzanne Krais is Chief Nursing Officer, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Monica Do
- Monica Do is Clinical Pharmacist, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Amy Hall
- Amy Hall is Senior Physical Therapist, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Holland Pace
- Holland Pace is Senior Occupational Therapist, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - David P Myers
- David P. Myers is Staff Pulmonologist, Pulmonary Critical Care Medicine, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Timothy J George
- Timothy J. George is Surgical Director of Mechanical Circulatory Support, Baylor Scott & White The Heart Hospital, Plano, Texas
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Cavayas YA, Munshi L, Del Sorbo L, Fan E. The Early Change in Pa CO2 after Extracorporeal Membrane Oxygenation Initiation Is Associated with Neurological Complications. Am J Respir Crit Care Med 2020; 201:1525-1535. [PMID: 32251606 DOI: 10.1164/rccm.202001-0023oc] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Large decreases in PaCO2 that occur when initiating extracorporeal membrane oxygenation (ECMO) in patients with respiratory failure may cause cerebral vasoconstriction and compromise brain tissue perfusion.Objectives: To determine if the magnitude of PaCO2 correction upon ECMO initiation is associated with an increased incidence of neurological complications in patients with respiratory failure.Methods: We conducted a multicenter, international, retrospective cohort study using the Extracorporeal Life Support Organization Registry, including adults with respiratory failure receiving ECMO via any mode between 2012 and 2017. The relative change in PaCO2 in the first 24 hours was calculated as (24-h post-ECMO PaCO2 - pre-ECMO PaCO2)/pre-ECMO PaCO2. The primary outcome was the occurrence of neurological complications, defined as seizures, ischemic stroke, intracranial hemorrhage, or brain death.Measurements and Main Results: We included 11,972 patients, 88% of whom were supported with venovenous ECMO. The median relative change in PaCO2 was -31% (interquartile range, -46% to -12%). Neurological complications were uncommon overall (6.9%), with a low incidence of seizures (1.1%), ischemic stroke (1.9%), intracranial hemorrhage (3.5%), and brain death (1.6%). Patients with a large relative decrease in PaCO2 (>50%) had an increased incidence of neurological complications compared with those with a smaller decrease (9.8% vs. 6.4%; P < 0.001). A large relative decrease in PaCO2 was independently associated with neurological complications after controlling for previously described risk factors (odds ratio, 1.7; 95% confidence interval, 1.3 to 2.3; P < 0.001).Conclusions: In patients receiving ECMO for respiratory failure, a large relative decrease in PaCO2 in the first 24 hours after ECMO initiation is independently associated with an increased incidence of neurological complications.
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Affiliation(s)
- Yiorgos Alexandros Cavayas
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, and.,Département de Médecine, Hôpital du Sacré-Coeur de Montréal, and.,Département de Chirurgie, Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; and
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, and
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, and
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Karagiannidis C, Windisch W, Bein T. Rapid Changes in Arterial Carbon Dioxide Levels Caused by Extracorporeal Membrane Oxygenation. The Temptation of a Fascinating Technology. Am J Respir Crit Care Med 2020; 201:1466-1468. [PMID: 32343600 PMCID: PMC7301726 DOI: 10.1164/rccm.202004-1060ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care MedicineCologne-Merheim HospitalCologne, Germany.,Witten/Herdecke University HospitalCologne, Germanyand
| | - Wolfram Windisch
- Department of Pneumology and Critical Care MedicineCologne-Merheim HospitalCologne, Germany.,Witten/Herdecke University HospitalCologne, Germanyand
| | - Thomas Bein
- Faculty of MedicineUniversity HospitalRegensburg, Germany
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Intracranial Hemorrhage and Extracorporeal Membrane Oxygenation: Chicken or the Egg? Crit Care Med 2017; 45:1781-1783. [PMID: 28915173 DOI: 10.1097/ccm.0000000000002632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clair MP, Rambaud J, Flahault A, Guedj R, Guilbert J, Guellec I, Durandy A, Demoulin M, Jean S, Mitanchez D, Chalard F, Sileo C, Carbajal R, Renolleau S, Léger PL. Prognostic value of cerebral tissue oxygen saturation during neonatal extracorporeal membrane oxygenation. PLoS One 2017; 12:e0172991. [PMID: 28278259 PMCID: PMC5344369 DOI: 10.1371/journal.pone.0172991] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/31/2017] [Indexed: 12/02/2022] Open
Abstract
Objectives Extracorporeal membrane oxygenation support is indicated in severe and refractory respiratory or circulatory failures. Neurological complications are typically represented by acute ischemic or hemorrhagic lesions, which induce higher morbidity and mortality. The primary goal of this study was to assess the prognostic value of cerebral tissue oxygen saturation (StcO2) on mortality in neonates and young infants treated with ECMO. A secondary objective was to evaluate the association between StcO2 and the occurrence of cerebral lesions. Study design This was a prospective study in infants < 3 months of age admitted to a pediatric intensive care unit and requiring ECMO support. Measurements The assessment of cerebral perfusion was made by continuous StcO2 monitoring using near-infrared spectroscopy (NIRS) sensors placed on the two temporo-parietal regions. Neurological lesions were identified by MRI or transfontanellar echography. Results Thirty-four infants <3 months of age were included in the study over a period of 18 months. The ECMO duration was 10±7 days. The survival rate was 50% (17/34 patients), and the proportion of brain injuries was 20% (7/34 patients). The mean StcO2 during ECMO in the non-survivors was reduced in both hemispheres (p = 0.0008 right, p = 0.03 left) compared to the survivors. StcO2 was also reduced in deceased or brain-injured patients compared to the survivors without brain injury (p = 0.002). Conclusion StcO2 appears to be a strong prognostic factor of survival and of the presence of cerebral lesions in young infants during ECMO.
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Affiliation(s)
- Marie-Philippine Clair
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Jérôme Rambaud
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Adrien Flahault
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology (CIRB), INSERM, U1050, Paris, France
- CNRS, UMR 7241, Paris, France
| | - Romain Guedj
- Department of Emergency medicine, Trousseau Hospital, AP-HP, Paris, France
| | - Julia Guilbert
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Isabelle Guellec
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Amélie Durandy
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Maryne Demoulin
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Sandrine Jean
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | | | - François Chalard
- Department of Pediatric Radiology, Trousseau Hospital, AP-HP, Paris, France
| | - Chiara Sileo
- Department of Pediatric Radiology, Trousseau Hospital, AP-HP, Paris, France
| | - Ricardo Carbajal
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
- Department of Emergency medicine, Trousseau Hospital, AP-HP, Paris, France
- UPMC Pierre et Marie Curie University, Paris VI, France
| | - Sylvain Renolleau
- Department of Pediatric intensive care unit, Necker Hospital, AP-HP, Paris, France
| | - Pierre-Louis Léger
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
- * E-mail:
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Muellenbach RM, Kilgenstein C, Kranke P, Küstermann J, Kredel M, Roewer N, Ernestus RI, Westermaier T. Effects of venovenous extracorporeal membrane oxygenation on cerebral oxygenation in hypercapnic ARDS. Perfusion 2013; 29:139-41. [PMID: 23887087 DOI: 10.1177/0267659113497073] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly used in ARDS patients with hypoxemia and/or severe hypercapnia refractory to conventional treatment strategies. However, it is associated with severe intracranial complications, e.g. ischemic or hemorrhagic stroke. The arterial carbon dioxide partial pressure (PaCO2) is one of the main determinants influencing cerebral blood flow and oxygenation. Since CO2 removal is highly effective during ECMO, reduction of CO2 may lead to alterations in cerebral perfusion. We report on the variations of cerebral oxygenation during the initiation period of ECMO treatment in a patient with hypercapnic ARDS, which may partly explain the findings of ischemic and/or hemorrhagic complications in conjunction with ECMO.
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de Mol AC, Gerrits LC, van Heijst AFJ, Menssen J, van der Staak FHJM, Liem KD. Effect of bladderbox alarms during venoarterial extracorporeal membrane oxygenation on cerebral oxygenation and hemodynamics in lambs. Pediatr Res 2009; 66:688-92. [PMID: 19707177 DOI: 10.1203/pdr.0b013e3181bce55c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
To determine the effects of bladderbox alarms during venoarterial extracorporeal membrane oxygenation (va-ECMO) on cerebral oxygenation and hemodynamics, six lambs were prospectively treated with va-ECMO and bladderbox alarms were simulated. Changes in concentrations of oxyhemoglobin (deltacO2Hb), deoxyhemoglobin (deltacHHb), and total Hb (deltactHb) were measured using near infrared spectrophotometry. Fluctuations in Hb oxygenation index (deltaHbD) and cerebral blood volume (deltaCBV) were calculated. Heart rate (HR), mean arterial pressure (MAP), blood flow in the left carotid artery (Qcar), and central venous pressure (CVP) were registered. Bladderbox alarms were simulated by increasing the ECMO flow or partially clamping the venous cannula and resolved by decreasing the ECMO flow, unclamping the cannula, or intravascular volume administration. CBV, HbD, MAP, and Qcar decreased significantly during bladderbox alarms, whereas HR and CVP increased. After the bladderbox alarms, CBV and HbD increased significantly to values above baseline. For HbD, this increase was higher during intravascular volume administration.MAP, Qcar, and CVP recovered to preexperiment values but increased further with volume administration. HR was increased at the end of our measurements. We conclude that Bladderbox alarms during va-ECMO treatment result in significant fluctuations in cerebral oxygenation and hemodynamics, a possible risk factor for intracranial lesions.
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Affiliation(s)
- Amerik C de Mol
- Department of Pediatrics, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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Naulaers G, Meyns B, Miserez M, Leunens V, Van Huffel S, Casaer P, Weindling M, Devlieger H. Use of tissue oxygenation index and fractional tissue oxygen extraction as non-invasive parameters for cerebral oxygenation. A validation study in piglets. Neonatology 2007; 92:120-6. [PMID: 17377413 DOI: 10.1159/000101063] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Accepted: 12/07/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the relation between cerebral tissue oxygenation index (TOI), measured with spatially resolved spectroscopy (SRS), and the different oxygenation parameters. To evaluate the relation between a new parameter named fractional tissue oxygen extraction (FTOE) and the cerebral fractional oxygen extraction (FOE). METHODS Six newborn piglets were measured at 33, 35, and 37 degrees C and in hypocapnia. Mean arterial blood pressure (MABP), haemoglobin (Hb), peripheral oxygen saturation (S(a)O(2)) and P(a)CO(2) were measured at each step. Cerebral blood flow (CBF) was measured by injection of coloured microspheres into the left atrium. Jugular bulb oxygen saturation (JVS), cerebral arterial and venous oxygen content (C(a)O(2) and C(v)O(2)) and FOE were calculated. TOI of the brain was calculated and FTOE was introduced as (S(a)O(2) - TOI)/S(a)O(2). The correlation was calculated with an ANCOVA test. RESULTS There was a positive correlation (R = 0.4 and p = 0.011) between TOI and JVS. No correlation was found with CBF, MABP or Hb. There was a positive correlation between P(a)CO(2) and cerebral TOI (R = 0.24 and p = 0.03). FTOE correlated well with FOE (R = 0.4 and p = 0.016) and there was a negative correlation between FTOE and P(a)CO(2) (R = 0.24, p = 0.03). CONCLUSION The measurement of TOI and FTOE by SRS correlated well with the cerebral venous saturation and FOE, respectively.
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Affiliation(s)
- Gunnar Naulaers
- Department of Paediatrics, University Hospital Leuven, Leuven, Belgium.
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Klaessens JH, Hopman JC, van Wijk MC, Djien Liem K, Thijssen JM. Assessment of local changes of cerebral perfusion and blood concentration by near infrared spectroscopy and ultrasound contrast densitometry. Brain Dev 2005; 27:406-14. [PMID: 16122627 DOI: 10.1016/j.braindev.2004.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2004] [Revised: 10/25/2004] [Accepted: 10/25/2004] [Indexed: 11/20/2022]
Abstract
The objective of this study is to correlate regional cerebral blood concentration measurements made with near infrared spectroscopy to simultaneous local measurements of ultrasound contrast agent (CA) densitometry. Experiments were performed with piglets (7 kg) under general anesthesia. The cerebral blood flow (CBF) and volume (CBV) were changed by inducing various degrees of hypercapnia. NIRS measurements were performed with a quasi-continuous wave system, using an optode distance of 3-6 cm. The concentration changes in oxygenated and deoxygenated hemoglobin and their sum and difference (cO2Hb, cHHb, ctHb, cHbD) were continuously calculated. Ultrasound contrast agent (SF6) was administered as a short intra-venous bolus. Ultrasound equipment was used in pulse inversion second harmonic gray scale imaging mode at low transmit power setting. Three regions-of-interest (0.25 cm2) were analyzed in each image. Wash-in curves were constructed as spatial mean gray level vs. time. The variables collected with both methods changed according to the induced changes in the physiological condition. Changes in the PaCO2, pH and carotid flow induced highly correlated changes in cO2Hb, cHHb, ctHb and cHbD, and in the variables derived from CA analyses. NIRS and CA methods measure regional, respectively, local changes in CBV and CBF. Moreover, NIRS can yield complementary information about the cerebral oxygenation.
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Affiliation(s)
- John H Klaessens
- Clinical Physics, Department of Pediatrics, University Medical Centre Nijmegen, 435, P.O. Box 9101, NL-6500 HB Nijmegen, The Netherlands.
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Klaessens JHGM, Kolkman RGM, Hopman JCW, Hondebrink E, Liem KD, Steenbergen W, de Mul FFM, Thijssen JM. Monitoring cerebral perfusion using near-infrared spectroscopy and laser Doppler flowmetry. Physiol Meas 2004; 24:N35-40. [PMID: 14658786 DOI: 10.1088/0967-3334/24/4/n03] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This paper describes the simultaneous use of two, noninvasive, near-infrared techniques near-infrared spectroscopy (NIRS) and a continuous wave NIR laser Doppler flow system (LDF) to measure changes in the blood oxygenation, blood concentration and blood flow velocity in the brain. A piglet was used as animal model. A controlled change in the arterial CO2 pressure (PaCO2) was applied for achieving changes in the listed cerebrovascular parameters. The time courses of blood concentration parameters (NIRS) and RMS blood flow velocity (LDF) were found to correspond closely with those of carotid blood flow and arterial carbon dioxide pressure (PaCO2). This result shows the additional value of LDF when combined with NIRS, preferably in one instrument. Development of pulsed LDF for regional blood flow measurement is indicated.
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Affiliation(s)
- J H G M Klaessens
- Clinical Physics Laboratory, University Children's Hospital Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Van Heijst A, Liem D, Hopman J, Van Der Staak F, Sengers R. Oxygenation and hemodynamics in left and right cerebral hemispheres during induction of veno-arterial extracorporeal membrane oxygenation. J Pediatr 2004; 144:223-8. [PMID: 14760266 DOI: 10.1016/j.jpeds.2003.11.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Oxygenation and hemodynamics in the left and right cerebral hemispheres were measured during induction of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). STUDY DESIGN Using near infrared spectrophotometry, effects of right common carotid artery (RCCA) and right internal jugular vein (RIJV) ligation and start of VA-ECMO on concentrations of oxyhemoglobin, deoxyhemoglobin, and cerebral blood volume (CBV) were evaluated in 10 newborn infants. Mean cerebral blood flow velocity (CBFV) in the major cerebral arteries was compared before and after the start of VA-ECMO (pulsed Doppler ultrasonography). RESULTS RCCA ligation caused a decrease in oxyhemoglobin concentration and an increase in deoxyhemoglobin concentration. RIJV ligation caused no changes. Sixty minutes after the start of VA-ECMO, oxyhemoglobin concentration and CBV had increased, and deoxyhemoglobin concentration had decreased. There were no differences between the hemispheres. Mean CBFV had increased in the left internal carotid artery, and it increased equally in both middle cerebral arteries. Flow direction was reversed in the right internal carotid artery. Three patients had asymmetric cerebral lesions, not related to differences in the measurements between the cerebral hemispheres. CONCLUSION The initiation of VA-ECMO causes changes in cerebral oxygenation and hemodynamics but without a difference in effect on left and right cerebral hemispheres.
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Affiliation(s)
- Arno Van Heijst
- Departments of Pediatrics and Pediatric Surgery, University Medical Centre Nijmegen, Nijmegen, The Netherlands.
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