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Bajaj JS, Kamath PS, Reddy KR, Asrani SK, Keaveny AP, Tandon P, Duarte-Rojo A, Kappus M, Verna E, Biggins SW, Vargas HE, Albhaisi S, Shaw J, Dahiya M, Filipek N, Fallahzadeh MA, Wegermann K, Cabello R, Bera C, Thuluvath P, Bush B, Thacker LR, Wong F. Predictors of Respiratory Failure Development in a Multicenter Cohort of Inpatients With Cirrhosis. Am J Gastroenterol 2024; 119:712-718. [PMID: 37938163 DOI: 10.14309/ajg.0000000000002574] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/18/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Hospitalized patients with cirrhosis can develop respiratory failure (RF), which is associated with a poor prognosis, but predisposing factors are unclear. METHODS We prospectively enrolled a multicenter North American cirrhosis inpatient cohort and collected admission and in-hospital data (grading per European Association for the Study of Liver-Chronic Liver Failure scoring system, acute kidney injury [AKI], infections [admission/nosocomial], and albumin use) in an era when terlipressin was not available in North America. Multivariable regression to predict RF was performed using only admission day and in-hospital events occurring before RF. RESULTS A total of 511 patients from 14 sites (median age 57 years, admission model for end-stage liver disease [MELD]-Na 23) were enrolled: RF developed in 15%; AKI occurred in 24%; and 11% developed nosocomial infections (NI). At admission, patients who developed RF had higher MELD-Na, gastrointestinal (GI) bleeding/AKI-related admission, and prior infections/ascites. During hospitalization, RF developers had higher NI (especially respiratory), albumin use, and other organ failures. RF was higher in patients receiving albumin (83% vs 59%, P < 0.0001) with increasing doses (269.5 ± 210.5 vs 208.6 ± 186.1 g, P = 0.01) regardless of indication. Admission for AKI, GI bleeding, and high MELD-Na predicted RF. Using all variables, NI (odds ratio [OR] = 4.02, P = 0.0004), GI bleeding (OR = 3.1, P = 0.002), albumin use (OR = 2.93, P = 0.01), AKI (OR = 3.26, P = 0.008), and circulatory failure (OR = 3.73, P = 0.002) were associated with RF risk. DISCUSSION In a multicenter inpatient cirrhosis study of patients not exposed to terlipressin, 15% of patients developed RF. RF risk was highest in those admitted with AKI, those who had GI bleeding on admission, and those who developed NI and other organ failures or received albumin during their hospital course. Careful volume monitoring and preventing nosocomial respiratory infections and renal or circulatory failures could reduce this risk.
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | | | - Andrew P Keaveny
- Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | | | - Andres Duarte-Rojo
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Northwestern University, Chicago, Illinois, USA
| | | | | | | | - Hugo E Vargas
- Mayo Clinic College of Medicine and Science, Phoenix, Arizona, USA
| | - Somaya Albhaisi
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Jawaid Shaw
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | | | | | | | | | | | | | - Paul Thuluvath
- Mercy Medical Center & University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brian Bush
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Leroy R Thacker
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
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Jo J, Crespo G, Gregory D, Sinha J, Xie J, Zhang M, Magee J, Barman P, Patel YA, Schluger A, Walters K, Biggins S, Filipek N, Cullaro G, Wong R, Lai JC, Perreault GJ, Verna EC, Sharma P, VanWagner LB. Factors associated with cardiovascular events after simultaneous liver-kidney transplant from the US Multicenter Simultaneous Liver-Kidney Transplant Consortium. Hepatol Commun 2023; 7:e2108. [PMID: 36285830 PMCID: PMC9827959 DOI: 10.1002/hep4.2108] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 01/17/2023] Open
Abstract
Cardiovascular disease is a leading complication after both liver and kidney transplantation. Factors associated with and rates of cardiovascular events (CVEs) after simultaneous liver-kidney transplant (SLKT) are unknown. This was a retrospective cohort study of adult SLKT recipients between 2002 and 2017 at six centers in six United Network for Organ Sharing regions in the US Multicenter SLKT Consortium. The primary outcome was a CVE defined as hospitalization due to acute coronary syndrome, arrhythmia, congestive heart failure, or other CV causes (stroke or peripheral vascular disease) within 1 year of SLKT. Among 515 SLKT subjects (mean age ± SD, 55.4 ± 10.6 years; 35.5% women; 68.1% White), 8.7% had a CVE within 1 year of SLKT. The prevalence of a CVE increased from 3.3% in 2002-2008 to 8.9% in 2009-2011 to 14.0% in 2012-2017 ( p = 0.0005). SLKT recipients with a CVE were older (59.9 vs. 54.9 years, p < 0.0001) and more likely to have coronary artery disease (CAD) (37.8% vs. 18.4%, p = 0.002) and atrial fibrillation (AF) (27.7% vs. 7.9%, p = 0.003) than those without a CVE. There was a trend toward older age by era of SLKT ( p = 0.054). In multivariate analysis adjusted for cardiac risk factors at transplant, age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02, 1.11), CAD (OR, 3.62; 95% CI, 1.60, 8.18), and AF (OR, 2.36; 95% CI, 1.14, 4.89) were associated with a 1-year CVE after SLKT. Conclusion : Among SLKT recipients, we observed a 4-fold increase in the prevalence of 1-year CVEs over time. Increasing age, CAD, and AF were the main potential explanatory factors for this trend independent of other risk factors. These findings suggest that CV risk protocols may need to be tailored to this high-risk population.
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Affiliation(s)
- Jennifer Jo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gonzalo Crespo
- Liver Transplant Unit, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Dyanna Gregory
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jasmine Sinha
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jiaheng Xie
- Division of Gastroenterology & Hepatology, University of Michigan, Michigan, Ann Arbor, USA
| | - Min Zhang
- Division of Gastroenterology & Hepatology, University of Michigan, Michigan, Ann Arbor, USA
| | - John Magee
- Division of Gastroenterology & Hepatology, University of Michigan, Michigan, Ann Arbor, USA
| | - Pranab Barman
- Division of Digestive and Liver Diseases, University of California, California, San Diego, USA
| | - Yuval A. Patel
- Division of Digestive and Liver Diseases, Duke University, North Carolina, Durham, USA
| | - Aaron Schluger
- Division of Digestive and Liver Diseases, Westchester Medical Center, New York, Westchester, USA
| | - Kara Walters
- Division of Gastroenterology & Hepatology, University of California, California, Los Angeles, USA
| | - Scott Biggins
- Division of Gastroenterology & Hepatology, University of Washington, Washington, Seattle, USA
| | - Natalia Filipek
- Division of Gastroenterology & Hepatology, University of Washington, Washington, Seattle, USA
| | - Giuseppe Cullaro
- Division of Digestive and Liver Diseases, University of California, California, San Francisco, USA
| | - Randi Wong
- Division of Digestive and Liver Diseases, University of California, California, San Francisco, USA
| | - Jennifer C. Lai
- Division of Digestive and Liver Diseases, University of California, California, San Francisco, USA
| | - Gabriel J. Perreault
- Division of Digestive and Liver Diseases, Columbia University, New York, New York, USA
| | - Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Columbia University, New York, New York, USA
| | - Pratima Sharma
- Division of Gastroenterology & Hepatology, University of Michigan, Michigan, Ann Arbor, USA
| | - Lisa B. VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Texas, Dallas, USA
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Sharma P, Xie J, Wang L, Zhang M, Magee J, Answine A, Barman P, Jo J, Sinha J, Schluger A, Perreault GJ, Walters KE, Cullaro G, Wong R, Filipek N, Biggins SW, Lai JC, VanWagner LB, Verna EC, Patel YA. Burden of early hospitalization after simultaneous liver-kidney transplantation: Results from the US Multicenter SLKT Consortium. Liver Transpl 2022; 28:1756-1765. [PMID: 35665591 PMCID: PMC11068063 DOI: 10.1002/lt.26523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/26/2022] [Accepted: 05/18/2022] [Indexed: 01/13/2023]
Abstract
The burden of early hospitalization (within 6 months) following simultaneous liver-kidney transplant (SLKT) is not known. We examined risk factors associated with early hospitalization after SLKT and their impact on patient mortality conditional on 6-month survival. We used data from the US Multicenter SLKT Consortium cohort study of all adult SLKT recipients between 2002 and 2017 who were discharged alive following SLKT. We used Poisson regression to model rates of early hospitalizations after SLKT. Cox regression was used to identify risk factors associated with mortality conditional on survival at 6 months after SLKT. Median age (N = 549) was 57.7 years (interquartile range [IQR], 50.6-63.9) with 63% males and 76% Whites; 33% had hepatitis C virus, 20% had non-alcohol-associated fatty liver disease, 23% alcohol-associated liver disease, and 24% other etiologies. Median body mass index (BMI) and Model for End-Stage Liver Disease-sodium scores were 27.2 kg/m2 (IQR, 23.6-32.2 kg/m2 ) and 28 (IQR, 23-34), respectively. Two-thirds of the cohort had at least one hospitalization within the first 6 months of SLKT. Age, race, hospitalization at SLKT, diabetes mellitus, BMI, and discharge to subacute rehabilitation (SAR) facility after SLKT were independently associated with a high incidence rate ratio of early hospitalization. Number of hospitalizations within the first 6 months did not affect conditional survival. Early hospitalizations after SLKT were very common but did not affect conditional survival. Although most of the risk factors for early hospitalization were nonmodifiable, discharge to SAR after initial SLKT was associated with a significantly higher incidence rate of early hospitalization. Efforts and resources should be focused on identifying SLKT recipients at high risk for early hospitalization to optimize their predischarge care, discharge planning, and long-term follow-up.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jiaheng Xie
- Department of Biostatistics, University of Michigan School of Public Health, Anna Arbor, Michigan, USA
| | - Leyi Wang
- Department of Biostatistics, University of Michigan School of Public Health, Anna Arbor, Michigan, USA
| | - Min Zhang
- Department of Biostatistics, University of Michigan School of Public Health, Anna Arbor, Michigan, USA
| | - John Magee
- Department of Surgery, Michigan Medicine, University of Michigan, Anna Arbor, Michigan, USA
| | - Adeline Answine
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Pranab Barman
- Division of Gastroenterology and Hepatology, University of California, San Diego, California, USA
| | - Jennifer Jo
- Department of Internal Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jasmine Sinha
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Aaron Schluger
- Department of Internal Medicine, Westchester Medical Center, Westchester, New York, USA
| | - Gabriel J. Perreault
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Kara E. Walters
- Division of Gastroenterology, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Giuseppe Cullaro
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Randi Wong
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Natalia Filipek
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Lisa B. VanWagner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA
| | - Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Yuval A. Patel
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
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Filipek N, Kirkham E, Chen M, Ma CC, Horn DL, Johnson KE, Parikh SR. Drug-induced sleep endoscopy directed surgery improves polysomnography measures in overweight and obese children with obstructive sleep apnea. Acta Otolaryngol 2021; 141:397-402. [PMID: 33372808 DOI: 10.1080/00016489.2020.1863465] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Obstructive sleep apnea affects approximately 1-4% of all children, with increased prevalence amongst overweight and obese children. OBJECTIVE To assess the effects of drug-induced sleep endoscopy (DISE)-directed surgery on polysomnography parameters in obese and overweight children. MATERIAL/METHODS A retrospective case-series was performed on obese and overweight pediatric patients who underwent clinically indicated DISE-directed surgery. Forty children met the inclusion criteria, including: body mass index ≥85%, DISE-study, and pre- and post-DISE polysomnography. Patients were divided into surgically naïve (n = 23) and prior adenotonsillectomy (n = 17) groups. Demographic and clinical characteristics were examined with chi-square and Wilcoxon rank-sum test. Polysomnography parameters were compared with Wilcoxon signed rank test. RESULTS Of 40 children with mean BMI 94% and mean age 8 ± 6 years old, 17 (43%) underwent a previous adenotonsillectomy. Overall, significant improvements were observed in the apnea-hypopnea index (AHI; 25.0 to 9.9 events/hour, p < .01) and oxygen nadir (82.7% to 88.5%, p < .01). A similar pattern was observed among the surgically naïve (AHI: 35.9 to 12.7 events/hour, p = .04; oxygen nadir: 79.7% to 86.4%, p = .2) and post-adenotonsillectomy groups (AHI: 10.4 to 6.2 events/hour, p = .02; oxygen nadir: 86.7% to 91.2%, p < .01). CONCLUSIONS/SIGNIFICANCE Polysomnography parameters significantly improved following DISE-directed interventions in obese and overweight children with obstructive sleep apnea.
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Affiliation(s)
- Natalia Filipek
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Erin Kirkham
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Maida Chen
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, Seattle, WA, USA
| | - Cheng Cheng Ma
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - David L. Horn
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Kaalan E. Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Sanjay R. Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA
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Kirkham E, Ma CC, Filipek N, Horn DL, Johnson K, Chen ML, Parikh SR. Polysomnography outcomes of sleep endoscopy-directed intervention in surgically naïve children at risk for persistent obstructive sleep apnea. Sleep Breath 2020; 24:1143-1150. [PMID: 31919717 DOI: 10.1007/s11325-019-02006-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/09/2019] [Accepted: 12/20/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Drug-induced sleep endoscopy (DISE) is useful in children with obstructive sleep apnea (OSA) that persists after adenotonsillectomy (AT), but its utility in surgically naïve children is unclear. We report polysomnography outcomes of surgically naïve children who underwent DISE-directed intervention because they were considered high risk for persistent OSA after adenotonsillectomy. METHODS This study is a case series of 62 surgically naïve children with OSA who were considered high risk for persistence after AT and underwent DISE-directed intervention with pre- and postoperative polysomnography between 2012 and 2016. Analysis was performed with the paired t test. RESULTS Children were on average 5.9 (± 5.5, 0.2-18.6) years old at the time of surgery, 68% male, 18% obese, and 60% white. Thirty-eight percent had a syndromic diagnosis: 19% trisomy 21, 11% hypotonic neuromuscular disorder, and 8% craniofacial condition. The remaining 62% were non-syndromic but underwent DISE because they had at least one risk factor for OSA persistence after AT (age > 7 years, black race, 1+ tonsils, obesity, and/or severe OSA). Forty-two percent underwent AT, while 58% underwent treatment other than AT, including 18% who had multilevel surgery. Children improved significantly in 4 out of 5 polysomnography parameters tested, including obstructive apnea-hypopnea index (oAHI; 22.2 to 7.2, p < 0.01) and oxygen nadir (82 to 87, p < 0.01). Thirty-eight (61%) had a postoperative oAHI < 5; 16 (21%) had a postoperative oAHI < 2. CONCLUSION DISE resulted in intervention other than AT in 58% of surgically naïve children at high risk for persistent OSA after AT. DISE-directed intervention resulted in significant mean improvement in postoperative OSA.
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Affiliation(s)
- Erin Kirkham
- Department of Otolaryngology: Head and Neck Surgery, The University of Michigan, Ann Arbor, MI, USA. .,Mott Children's Hospital, University of Michigan Medical Center, 1540 E. Hospital Dr. CW 5-702, SPC 4241, Ann Arbor, MI, 48109, USA.
| | - Cheng-Cheng Ma
- Department of Otolaryngology: Head and Neck Surgery, The University of Washington School of Medicine, Seattle, WA, USA
| | - Natalia Filipek
- Department of Otolaryngology: Head and Neck Surgery, The University of Washington School of Medicine, Seattle, WA, USA
| | - David L Horn
- Department of Otolaryngology: Head and Neck Surgery, The University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Hospital, Seattle, WA, USA
| | - Kaalan Johnson
- Department of Otolaryngology: Head and Neck Surgery, The University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Hospital, Seattle, WA, USA
| | - Maida L Chen
- Seattle Children's Hospital, Seattle, WA, USA.,Department of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Sanjay R Parikh
- Department of Otolaryngology: Head and Neck Surgery, The University of Washington School of Medicine, Seattle, WA, USA.,Seattle Children's Hospital, Seattle, WA, USA
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Miller C, Kirkham E, Ma C, Filipek N, Horn DL, Johnson K, Chen ML, Parikh SR. Polysomnography outcomes in children with small tonsils undergoing drug‐induced sleep endoscopy–directed surgery. Laryngoscope 2018; 129:2771-2774. [DOI: 10.1002/lary.27759] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Craig Miller
- Department of Otolaryngology–Head and Neck Surgery Seattle, Washington
- Department of Pediatrics Pulmonary and Sleep Medicine, University of Washington School of Medicine Seattle, Washington
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Erin Kirkham
- Department of Otolaryngology–Head and Neck Surgery Seattle, Washington
- Department of Pediatrics Pulmonary and Sleep Medicine, University of Washington School of Medicine Seattle, Washington
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Cheng‐Cheng Ma
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Natalia Filipek
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - David L. Horn
- Department of Otolaryngology–Head and Neck Surgery Seattle, Washington
- Department of Pediatrics Pulmonary and Sleep Medicine, University of Washington School of Medicine Seattle, Washington
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Kaalan Johnson
- Department of Otolaryngology–Head and Neck Surgery Seattle, Washington
- Department of Pediatrics Pulmonary and Sleep Medicine, University of Washington School of Medicine Seattle, Washington
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Maida L. Chen
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
| | - Sanjay R. Parikh
- Department of Otolaryngology–Head and Neck Surgery Seattle, Washington
- Department of Pediatrics Pulmonary and Sleep Medicine, University of Washington School of Medicine Seattle, Washington
- Seattle Children's Hospital Seattle, Washington
- Department of Pediatrics, Pulmonary and Sleep MedicineUniversity of Washington School of Medicine Seattle, Washington U.S.A
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