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Chean D, Windsor C, Lafarge A, Dupont T, Nakaa S, Whiting L, Joseph A, Lemiale V, Azoulay E. Severe Community-Acquired Pneumonia in Immunocompromised Patients. Semin Respir Crit Care Med 2024; 45:255-265. [PMID: 38266998 DOI: 10.1055/s-0043-1778137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Due to higher survival rates with good quality of life, related to new treatments in the fields of oncology, hematology, and transplantation, the number of immunocompromised patients is increasing. But these patients are at high risk of intensive care unit admission because of numerous complications. Acute respiratory failure due to severe community-acquired pneumonia is one of the leading causes of admission. In this setting, the need for invasive mechanical ventilation is up to 60%, associated with a high hospital mortality rate of around 40 to 50%. A wide range of pathogens according to the reason of immunosuppression is associated with severe pneumonia in those patients: documented bacterial pneumonia represents a third of cases, viral and fungal pneumonia both account for up to 15% of cases. For patients with an undetermined etiology despite comprehensive diagnostic workup, the hospital mortality rate is very high. Thus, a standardized diagnosis strategy should be defined to increase the diagnosis rate and prescribe the appropriate treatment. This review focuses on the benefit-to-risk ratio of invasive or noninvasive strategies, in the era of omics, for the management of critically ill immunocompromised patients with severe pneumonia in terms of diagnosis and oxygenation.
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Affiliation(s)
- Dara Chean
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Camille Windsor
- Medical Intensive Care Unit, AP-HP Henri Mondor University Hospital, Créteil, France
| | - Antoine Lafarge
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Thibault Dupont
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Sabrine Nakaa
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Livia Whiting
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Adrien Joseph
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, AP-HP Saint-Louis University Hospital, Paris, France
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Whiting L, Bianchi N, Faouzi M, Schneider A. Kinetics of small and middle molecule clearance during continuous hemodialysis. Sci Rep 2023; 13:12905. [PMID: 37558740 PMCID: PMC10412530 DOI: 10.1038/s41598-023-40075-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 08/04/2023] [Indexed: 08/11/2023] Open
Abstract
Regional citrate anticoagulation (RCA) enables prolonged continuous kidney replacement therapy (CKRT) filter lifespan. However, membrane diffusive performance might progressively decrease and remain unnoticed. We prospectively evaluated the kinetics of solute clearance and factors associated with decreased membrane performance in 135 consecutive CKRT-RCA circuits (35 patients). We recorded baseline patients' characteristics and clinical signs of decreased membrane performance. We calculated effluent/serum ratios (ESR) as well as respective clearances for urea, creatinine and β2-microglobuline at 12, 24, 48 and 72 h after circuit initiation. Using mixed-effects logistic regression model analyses, we assessed the effect of time on those values and determined independent predictors of decreased membrane performance as defined by an ESR for urea < 0.81. We observed a minor but statistically significant decrease in both ESR and solute clearance across the duration of therapy for all three solutes. We observed decreased membrane performance in 31 (23%) circuits while clinical signs were present in 19 (14.1%). The risk of decreased membrane performance significantly increased over time: 1.8% at T1 (p = 0.16); 7.3% at T2 (p = 0.01); 15.7% at T3 (p = 0.001) and 16.4% at T4 (p < 0.003). Four factors present within 24 h of circuit initiation were independently associated with decreased membrane performance: arterial blood bicarbonate level (OR 1.50; p < 0.001), activated partial thromboplastin time (aPTT; OR = 0.93; p = 0.02), fibrinogen level (OR 6.40; p = 0.03) and Charlson score (OR 0.10; p < 0.01). COVID-19 infection was not associated with increased risk of decreased membrane performance. Regular monitoring of ESR might be appropriate in selected patients undergoing CKRT.
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Affiliation(s)
- Livia Whiting
- Service de Médecine Intensive Adulte (SMIA), Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nathan Bianchi
- Service de Médecine Intensive Adulte (SMIA), Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Mohamed Faouzi
- Division of Biostatistics, Center for Primary Care and Public Health (UNISANTE), University of Lausanne, Lausanne, Switzerland
| | - Antoine Schneider
- Service de Médecine Intensive Adulte (SMIA), Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
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Whiting L, Bianchi NA, Alouazen K, Joannes-Boyau O, Chiche JD, Schneider A. Validation of a Protocol for Continuous Hemodiafiltration with Regional Citrate Anticoagulation with Omni®. Blood Purif 2022; 51:1039-1047. [PMID: 35636389 PMCID: PMC9808739 DOI: 10.1159/000524329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/22/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Omni® (B Braun, Melsungen, Germany) is able to run continuous renal replacement therapy (CRRT) in continuous veno-venous hemofiltration (CVVH), hemodialysis (CVVHD), and hemodiafiltration (CVVHDF) modes. However, to date, there is no validated protocol to guide the use of Omni® in CVVHDF mode with regional citrate anticoagulation (RCA). METHODS We designed a protocol for CVVHDF-RCA tailored for Omni®. This protocol was tested in patients included in an observational study conducted in our center between January and March 2021. For all study patients, we collected baseline characteristics, laboratory results, CRRT circuit lifespan as well as plasma and effluent samples at 12, 24, 48, and 72 h of CRRT circuit initiation. At each study time point, we computed urea, creatinine, and β2-microglobulin clearance as well as effluent/blood ratios. Data from circuits in CVVHDF-RCA mode are compared with those in standard therapy (CVVHD-RCA) with the same device. RESULTS We analyzed ten circuits (5 patients) in CVVHDF-RCA mode and 32 (13 patients) in CVVHD-RCA mode. No adverse events related to the therapy were observed. In CVVHDF-RCA mode, median circuit running time was 68 (IQR 8.1) hours versus 46 (IQR 9.0) in CVVHD mode, p = 0.053. Therapy adaptations (dialysate rate and/or blood flow) were required in one (10%) circuit (15.6% in CVVHD mode, p = 0.56). Compared to CVVHD, CVVHDF was able to achieve similar clearance and effluent/blood ratio for urea, creatinine, and β2-microglobulin across the entire duration of circuit lifetime. CONCLUSION The proposed protocol for CVVHDF-RCA for Omni® was associated with similar circuit lifetime, number of required adaptations and clearances to standard CVVHD-RCA. It appears to be safe and feasible.
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Affiliation(s)
- Livia Whiting
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland,
| | - Nathan Axel Bianchi
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Karima Alouazen
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation Sud, Centre Médico-Chirurgical Magellan, Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Jean-Daniel Chiche
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Antoine Schneider
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Affiliation(s)
- P. Mucavele
- Children’s Food Trust Sheffield UK
- Department of Nutrition and Dietetics King's College London UK
| | - C. Wall
- Children’s Food Trust Sheffield UK
- Food and Nutrition Group Sheffield Hallam University Sheffield UK
| | - L. Whiting
- Children’s Food Trust Sheffield UK
- Mellors Catering Services Sheffield UK
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Longchamp A, Longchamp J, Manzocchi‐Besson S, Whiting L, Haller C, Jeanneret S, Godio M, Garcia Martinez JJ, Bonjour T, Caillat M, Maitre G, Thaler JM, Pantet R, Donner V, Dumoulin A, Emonet S, Greub G, Friolet R, Robert‐Ebadi H, Righini M, Sanchez B, Delaloye J. Venous thromboembolism in critically Ill patients with COVID-19: Results of a screening study for deep vein thrombosis. Res Pract Thromb Haemost 2020; 4:842-847. [PMID: 32685893 PMCID: PMC7272794 DOI: 10.1002/rth2.12376] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/09/2020] [Accepted: 05/12/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The rapid spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and coronavirus disease 2019 (COVID-19), has caused more than 3.9 million cases worldwide. Currently, there is great interest to assess venous thrombosis prevalence, diagnosis, prevention, and management in patients with COVID-19. OBJECTIVES To determine the prevalence of venous thromboembolism (VTE) in critically ill patients with COVID-19, using lower limbs venous ultrasonography screening. METHODS Beginning March 8, we enrolled 25 patients who were admitted to the intensive care unit (ICU) with confirmed SARS-CoV-2 infections. The presence of lower extremity deep vein thrombosis (DVT) was systematically assessed by ultrasonography between day 5 and 10 after admission. The data reported here are those available up to May 9, 2020. RESULTS The mean (± standard deviation) age of the patients was 68 ± 11 years, and 64% were men. No patients had a history of VTE. During the ICU stay, 8 patients (32%) had a VTE; 6 (24%) a proximal DVT, and 5 (20%) a pulmonary embolism. The rate of symptomatic VTE was 24%, while 8% of patients had screen-detected DVT. Only those patients with a documented VTE received a therapeutic anticoagulant regimen. As of May 9, 2020, 5 patients had died (20%), 2 remained in the ICU (8%), and 18 were discharged (72%). CONCLUSIONS In critically ill patients with SARS-CoV-2 infections, DVT screening at days 5-10 of admission yielded a 32% prevalence of VTE. Seventy-five percent of events occurred before screening. Earlier screening might be effective in optimizing care in ICU patients with COVID-19.
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Affiliation(s)
- Alban Longchamp
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
- Department of Vascular SurgeryCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
- Department of Vascular SurgeryCentre Hospitalier Universitaire Vaudois and University of LausanneLausanneSwitzerland
| | - Justine Longchamp
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
- Department of Vascular SurgeryCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Sara Manzocchi‐Besson
- Department of Vascular SurgeryCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
- Division of Angiology and HaemostasisFaculty of MedicineGeneva University HospitalsGenevaSwitzerland
| | - Livia Whiting
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Claude Haller
- Department of Vascular SurgeryCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Séverin Jeanneret
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Manoelle Godio
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Juan Jose Garcia Martinez
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Thierry Bonjour
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Mary Caillat
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Guillaume Maitre
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Julian Matthias Thaler
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Rémy Pantet
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Viviane Donner
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Alexis Dumoulin
- Department of Infectious DiseasesInstitut Central des HôpitauxHôpital du ValaisSionSwitzerland
| | - Stéphane Emonet
- Department of Infectious DiseasesInstitut Central des HôpitauxHôpital du ValaisSionSwitzerland
| | - Gilbert Greub
- Department of Infectious DiseasesInstitute of MicrobiologyCentre Hospitalier Universitaire VaudoisLausanneSwitzerland
| | - Raymond Friolet
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Helia Robert‐Ebadi
- Division of Angiology and HaemostasisFaculty of MedicineGeneva University HospitalsGenevaSwitzerland
| | - Marc Righini
- Division of Angiology and HaemostasisFaculty of MedicineGeneva University HospitalsGenevaSwitzerland
| | - Bienvenido Sanchez
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
| | - Julie Delaloye
- Department of Intensive Care MedicineCentre Hospitalier du Valais Romand de l'Hôpital du Valais (site de Sion)SionSwitzerland
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Whiting L, Danaher RN, Ruggiero K, Lee CC, Chaussade C, Mulvey T, Phillips A, Loomes KM. D-chiro-inositol attenuates epinephrine-stimulated hepatic glucose output in the isolated perfused liver independently of insulin. Horm Metab Res 2013; 45:394-7. [PMID: 23225249 DOI: 10.1055/s-0032-1330016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
D-chiro-Inositol (DCI) is a cyclic sugar alcohol that evokes both antidiabetic and insulin sensitizing effects. Pharmacological administration of DCI has been shown to lower blood glucose in rat models of diabetes mellitus and enhance insulin sensitivity in humans with polycystic ovary syndrome (PCOS). We hypothesised that the antidiabetic effects of DCI could be due to inhibition of hepatic glucose output (HGO). To test this hypothesis, we perfused isolated rat livers either with buffer, myo-inositol, DCI, or insulin, and investigated their respective effects on the stimulation of HGO by epinephrine. We found that perfusion with 200 μM DCI attenuated epinephrine-stimulated HGO by 35% over 30 min as compared to the buffer control perfusion (p=0.05). By comparison, perfusion with 1 nM insulin attenuated epinephrine-stimulated HGO by 57% (p<0.0001). The glucose-lowering effects by DCI occurred independently of insulin and were specific to the DCI stereoisomer as 200 μM myo-inositol had no effect. These findings suggest that DCI could evoke its antidiabetic effects in vivo by inhibition of HGO. Further identification of the protein targets involved could open up new avenues to regulate hyperglycaemia with wider implications for the treatment of hepatic insulin resistance in PCOS.
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Affiliation(s)
- L Whiting
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
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Bailey RJ, Walker CS, Ferner AH, Loomes KM, Prijic G, Halim A, Whiting L, Phillips ARJ, Hay DL. Pharmacological characterization of rat amylin receptors: implications for the identification of amylin receptor subtypes. Br J Pharmacol 2012; 166:151-67. [PMID: 22014233 DOI: 10.1111/j.1476-5381.2011.01717.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Amylin (Amy) is an important glucoregulatory peptide and AMY receptors are clinical targets for diabetes and obesity. Human (h) AMY receptor subtypes are complexes of the calcitonin (CT) receptor with receptor activity-modifying proteins (RAMPs); their rodent counterparts have not been characterized. To allow identification of the most clinically relevant receptor subtype, the elucidation of rat (r) AMY receptor pharmacology is necessary. EXPERIMENTAL APPROACH Receptors were transiently transfected into COS-7 cells and cAMP responses measured in response to different agonists, with or without antagonists. Competition binding experiments were performed to determine rAmy affinity. KEY RESULTS rCT was the most potent agonist of rCT((a)) receptors, whereas rAmy was most potent at rAMY(1(a)) and rAMY(3(a)) receptors. rAmy bound to these receptors with high affinity. Rat α-calcitonin gene-related peptide (CGRP) was equipotent to rAmy at both AMY receptors. Rat adrenomedullin (AM) and rAM2/intermedin activated all three receptors but were most effective at rAMY(3(a)) . AC187, AC413 and sCT(8-32) were potent antagonists at all three receptors. rαCGRP(8-37) displayed selectivity for rAMY receptors over rCT((a)) receptors. rAMY(8-37) was a weak antagonist but was more effective at rAMY(1(a)) than rAMY(3(a)) . CONCLUSIONS AND IMPLICATIONS AMY receptors were generated by co-expression of rCT((a)) with rRAMP1 or 3, forming rAMY(1(a)) and rAMY(3(a)) receptors, respectively. CGRP was more potent at rAMY than at hAMY receptors. No antagonist tested was able to differentiate the rAMY receptor subtypes. The data emphasize the need for and provide a useful resource for developing new CT or AMY receptor ligands as pharmacological tools or potential clinical candidates.
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Affiliation(s)
- R J Bailey
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
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Affiliation(s)
- L Whiting
- Child Health Nursing, University of Hertfordshire
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Gibelman M, Whiting L. Negotiating and contracting in a managed care environment: considerations for practitioners. Health Soc Work 1999; 24:180-190. [PMID: 10505279 DOI: 10.1093/hsw/24.3.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The world of integrated service provider networks, managed care providers, and preferred provider systems requires clinical social workers to become skilled in business negotiations, with specific attention to contracting for services. This article focuses on the components of negotiating and successfully competing for contracts to gain access to and participate in provider networks for the delivery of mental health services. The authors identify critical elements involved in contracting for services from the perspective of social work practitioners who are now working with or who plan to work with managed care organizations. This pragmatic approach recognizes the controversial nature of social workers' relationship with managed care organizations and the ethical dilemmas that affect both the quality and quantity of client services.
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Affiliation(s)
- M Gibelman
- Wurzweiler School of Social Work, Yeshiva University, New York, NY 10033, USA.
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Abstract
Self-reported narcissism, self-esteem, and perceptions of parents as nurturing were examined in a sample of 459 undergraduates. In zero-order and partial correlations, dimensions from the Narcissistic Personality Inventory displayed inter-relationships and linkages with self-esteem and parental nurturance that conformed with the hypothesis that indices of narcissism fall along a continuum of mental health. Partial correlations controlling for self-esteem also indicated that at least some data for the more adaptive aspects of narcissism were mediated by healthier self-functioning. These results support recent suggestions that narcissism must be conceptualized within frameworks that include healthy self-esteem.
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Affiliation(s)
- P J Watson
- Department of Psychology, University of Tennessee at Chattanooga 37403
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Whiting L. Child abuse and neglect: a different perspective. Public Welf 1979; 36:22-5. [PMID: 10294878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Whiting L. Defining emotional neglect. Child Today 1976; 5:2-5. [PMID: 1245134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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