Microbial otitis media: recent advancements in treatment, current challenges and opportunities

Otitis media (OM) is a common disease affecting humans, especially paediatric populations. OM refers to inflammation of the middle ear and can be broadly classified into two types, acute and chronic. Bacterial infection is one of the most common causes of OM. Despite the introduction of vaccines, the incidence of OM remains significantly high worldwide. In this mini-review article, we discuss the recent treatment modalities for OM, such as suspension gel, transcutaneous immunization, and intranasal and transtympanic drug delivery, including therapies that are currently undergoing clinical trials. We provide an overview of how these recent advancements in therapeutic strategies can facilitate the circumvention of current treatment challenges involving preadolescence soft palate dysfunction, biofilm formation, tympanic membrane (ear drum) barrier and the attainment of efficacious drug concentrations in the middle ear. While traditional first-line immunization strategies are generally not very efficacious against biofilms, new technologies that use transdermal or intranasal drug delivery via chitosan-PsaA nanoparticles have shown promising results in experimental animal models of OM. Sustained drug delivery systems such as penta-block copolymer poloxamer 407-polybutylphosphoester (P407-PBP) or poloxamer 407 (e.g. OTO-201, with the brand name 'OTIPRIO') have demonstrated that treatments can be reduced to a single topical application. The emergence of effective new treatment modalities opens up promising new avenues for the treatment of OM that could lead to improved quality of life for many children and their families.

Local drug delivery in the urinary tract: current challenges and opportunities

Drug delivery is an important consideration in disease treatment. There are many opportunities for novel methods and technologies to hold promising roles in overcoming traditional obstacles. Delivery systems functionalised to boast synergistic antimicrobial effects, specific targeting, and enhanced bioavailability allow for improved therapeutic potential and better patient outcomes. Many of these delivery modalities find clinical practicality in the field of urology, specifically in the treatment of urinary tract infections (UTIs) and offer advantages over conventional methods. The aim of this review article is to discuss the current modalities of treatment for UTIs and the recent technological advancements for optimising drug delivery. We focus on challenges that persist in drug delivery during UTIs including barriers to antimicrobial penetration, drug resistance, biofilm formation and specific targeting limitations. With a discussion on how emerging methods combat these concerns, we present an overview of potential therapies with special emphasis on nanoparticle-based applications.

Training respite care providers for families with handicapped children: Experimental analysis and validation of an instructional package

We conducted four experiments to evaluate a respite care training package. In Experiment 1, we assessed the effectiveness of an instructional manual on the acquisition of respite care skills and compared the relative effects of three different manual on the acquisition of respite care skills and compared the relative effects of three different manual presentation formats. Results showed that performance during simulated (role-played) respite care situations improved substantially for all six trainees following presentation of the instructional manual (with no significant differences between presentation formats) although some remedial training was necessary to achieve mastery criterion. In Experiment 2, we evaluated the effects of the manual presented as a whole with a larger group of trainees and compared it to a workshop training approach. Results showed that both the instructional manual and workshop training approaches were effective, but that the former appeared to be more cost-effective. In both experiments, correct responding generalized to a respite care situation with a multiply handicapped child. In addition, several measures of social validity were obtained. In Experiment 3, we evaluated a simplified training and assessment package that could be conducted using the resources typically available to respite care agencies, and in Experiment 4, we demonstrated that respite care agency personnel could successfully implement this program.

A Triassic Fauna from Madagascar, Including Early Dinosaurs

The discovery of a Middle to Late Triassic ( approximately 225 to 230 million years old) terrestrial vertebrate fauna from Madagascar is reported. This fauna documents a temporal interval not well represented by continental vertebrate assemblages elsewhere in the world. It contains two new prosauropod dinosaurs, representing some of the earliest dinosaur occurrences known globally. This assemblage provides information about the poorly understood transition to the dinosaur-dominated faunas of the latest Triassic.

Neck posture and feeding habits of two jurassic sauropod dinosaurs

Articulated digital reconstructions of two diplodocid sauropods revealed cervical poses and feeding envelopes. The necks of Diplodocus and Apatosaurus were nearly straight but gently declined such that the heads, which were themselves angled downward relative to the neck, were close to ground level in their neutral, undeflected posture. Both necks were less flexible than conventionally depicted, and Diplodocus was less capable of lateral and dorsal curvature than Apatosaurus. The results suggest that these sauropods were adapted to ground feeding or low browsing, contrary to the view that diplodocid sauropods were high browsers.

Haloacetate-induced oxidative damage to DNA in the liver of male B6C3F1 mice

Brominated and chlorinated haloacetates (HAs) are by-products of drinking water disinfection. Dichloroacetate (DCA) and trichloroacetate (TCA) are hepatocarcinogenic in rodents, but the brominated analogs have received little study. Prior work has indicated that acute doses of the brominated derivatives are more potent inducers of oxidative stress and increase the 8-hydroxydeoxyguanosine (8-OH-dG) content of the nuclear DNA in the liver. Since, DCA and TCA are also known as weak peroxisome proliferators, the present study was intended to determine whether this activity might be exacerbated by peroxisomal proliferation. Classical responses to peroxisome proliferators, cyanide-insensitive acyl-CoA oxidase activity and increased 12-hydroxylation of lauric acid, were elevated in a dose-related manner in mice maintained on TCA and clofibric acid (positive control), but not with DCA, dibromoacetate (DBA) or bromochloroacetate (BCA). Administration of the HAs in drinking water to male B6C3F1 mice for periods from 3 to 10 weeks resulted in dose-related increases in 8-OH-dG in nuclear DNA of the liver with DBA and BCA, but not with TCA or DCA. These findings indicate that oxidative damage induced by the haloacetates is, at least in part, independent of peroxisome proliferation. In addition, these data suggest that oxidative damage to DNA may play a more important role in the chronic toxicology of brominated compared to the chlorinated haloacetates.

Lipid peroxidation and formation of 8-hydroxydeoxyguanosine from acute doses of halogenated acetic acids

Chlorinated, brominated, and mixed bromochloro acetates are major by-products of water disinfection by chlorine or ozone. The chlorinated acetates, trichloroacetate (TCA) and dichioroacetate (DCA), are carcinogenic in rodents. Brominated analogs of TCA and DCA have received little study. TCA and DCA induce lipid peroxidation in the livers of rodents when administered acutely. Oxidative stress can also result in oxidative damage to DNA, most commonly measured as increases in 8-hydroxydeoxyguanosine (8-OHdG) adducts. In this study, the ability of acute doses of TCA, DCA, dibromoacetate (DBA), bromodichloroacetate (BDCA), and bromochloroacetate (BCA) to induce lipid peroxidation and 8-OHdG formation was examined. Male B6C3F1 mice developed significant increases in 8-OHdG/dG ratios in nuclear DNA isolated from livers when treated with haloacetates. The extent of 8-OHdG formation appeared to be related to the ability to induce thiobarbituric acid-reactive substances (TBARS). The order of potency was DBA = BCA > BDCA > DCA > TCA. The induction of 8-OHdG was found to be generally more sensitive to treatment with haloacetates than the TBARS response. Significantly elevated levels of 8-OHdG were observed at doses of DBA, BCA, and BDCA as low as 30 mg/kg. We suggest that formation of 8-OHdG by brominated haloacetates may contribute to their toxicological effects.

Part 2: using a competency-based curriculum to train experienced nurses in ventilator care

As pediatric nurses, we are caring for increasing numbers of children with special health needs such as tracheostomy and ventilator care. These children are being discharged to their families requiring specialized care, including in-home skilled nursing services. In Part I of this two-part series, the authors described the development of a training curriculum for nurses caring for ventilator-assisted children at home. The next step was to validate that the curriculum was effective, feasible, and replicable. Part 2 describes the initial validation efforts with hospital and home care nurses.

Developing a competency-based curriculum for tracheostomy and ventilator care

Advances in technology and medical practice have enabled children with special health needs, such as tracheostomy and ventilator care, to be discharged to their families while continuing to require specialized care. Yet, corresponding increases in the availability and competence of home care providers have not kept pace with this trend. The authors set a goal to design, develop, implement, validate, and disseminate a competency-based curriculum to prepare adults to care for these children in the home and community. This article is Part 1 of a two-part series.

Training parents to observe and record: a data-based outcome evaluation of a pilot curriculum

Despite the prevalence of training parents in the use of child behavior management strategies, relatively little investigative attention has been devoted to promoting acquisition of parent observational and recording skills. In this study, we examined the efficacy of a brief curriculum designed to teach parents how to observe and record targeted child behaviors systematically. Subsequent to instruction, each of six participating parents demonstrated, in an analogue context, higher levels of both occurrence and nonoccurrence agreement, based upon their recordings of child behavior, when compared with those of a panel of experienced professionals. Agreement of parental recordings with those of professionals typically increased to a predetermined mastery criterion and stabilized subsequent to training, relative to a high degree of variability during baseline. Results are discussed in terms of directions for further refinement of the curriculum and additional study of its impact.

Behavior management in the child with developmental disabilities

Pediatricians who serve children with developmental disabilities would be well advised to study and practice applied behavior analysis. Within a behavior analytic framework, the pediatrician views the child's aberrant performance as being a constellation of behavioral excesses and skill deficits that serve a functional purpose, rather than as being a symptom of some underlying illness or intrapsychic mechanism. The pediatrician can counsel the child, parents, and teachers to rearrange their environment, with an emphasis on how they can behave differently toward one another in specific situations, so as to alter the target behavior. When the child's problem behaviors are relatively severe or intractable, the pediatrician can refer the patient and family to a behavior specialist while continuing to support efforts to improve the child's overall health and adjustment.

Measurement of Microscale Patchiness in a Turbulent Aquatic Odor Plume Using a Semiconductor-Based Microprobe

The distribution of chemical signals within aquatic environments is highly patchy and heterogeneous due to dispersion by turbulent eddies. We aimed to quantify the smallest spatial scales associated with chemical patches, and therefore measured the structure of chemical signals under turbulent flow simultaneously at two chemical sensors spaced from 200 to 800 {mu}m apart. Measurements were done under controlled stimulus and flow conditions with a novel semiconductor-based, multisite, microelectrochemical electrode (5-2000 {mu}m2 surface area sensors) and a high-speed computer-based recording system. The chemical signals received at the sensor were intermittent, with wide fluctuations in concentration. Patchiness in signal structure was found at spatial scales as small as 200 {mu}m. Significant differences in signal height were found between recordings made at probes spaced 200, 400, 600, and 800 {mu}m apart. These data demonstrate that sub-millimeter patches occur in aquatic turbulent odor plumes. Such differences in chemical signal structure over small spatial scales might be important for marine animals that employ olfactory orientation. We propose alternative ways by which organisms might deal with these fine scale differences in odor concentration. Animals much larger than microscale patches may have evolved elongated olfactory organs that integrate signals, thereby smoothing variations in sensory input. Animals about the same size as micropatches may be able to capitalize on microscale variation by extracting directional information from turbulent odor plumes.

Teaching developmentally disabled children with chronic illness to swallow prescribed capsules

Child noncompliance with prescribed medical regimens, including nonacceptance of oral medication, frequently impedes medical treatment and achievement of clinical aims. During this study, we used a single-subject experimental design to evaluate the effectiveness of a capsule-swallowing training curriculum specifically developed to promote acceptance of oral medication by multihandicapped children. Four such children participated, each diagnosed with a chronic pediatric illness requiring daily intake of oral medication. Training consisted of verbal instruction, demonstration, reinforcement for swallowing candies/capsules progressively larger in size, ignoring mild inappropriate behavior, and gradually providing less guidance and structure. In each case, the curriculum produced routine independent swallowing of prescribed capsules/tablets. Follow-up assessments, coupled with parent satisfaction ratings, suggest that skill acquisition was both enduring and clinically significant. This study validates a brief, readily exportable, and effective approach to teaching handicapped children to swallow capsules.

Phone phobia, phact or phantasy? An operant approach to a child's disruptive behavior induced by telephone usage

The clinical efficacy of a contingency management program for treating a developmentally disabled girl referred for telephone phobia was evaluated using both a multiple baseline across settings design and a reversal design. A descriptive analysis indicated that the 'phobia' was in all probability an operant, rather than a respondent. The treatment, consisting of differential reinforcement, extinction and time-out, was effective in reducing the frequency and intensity of disruptive behaviors in response to telephone usage. Follow-up assessments at 1, 3, and 6 months revealed that treatment gains were maintained.

Teaching self-administration of suctioning to children with tracheostomies

We examined the effectiveness of using dolls to teach young children with tracheostomies to self-administer a suctioning procedure. Four children between the ages of 5 and 8 years, who had had tracheostomies for 6 months or longer, participated. After skills were taught via doll-centered simulations, in vivo skills were evaluated. All of the training and probe sessions were conducted in the participants' classrooms or homes. Results of a multiple baseline design across subjects and skill components indicated that the performance of all children improved as a function of training. Skill maintenance was demonstrated by all participants during follow-up assessments conducted 2 to 6 weeks posttraining. Results of a questionnaire completed by caregivers and interviews with the children revealed high levels of satisfaction with the training procedures and outcomes.

Teaching self-catheterization skills to children with neurogenic bladder complications

We examined the effects of simulation training on the acquisition of self-catheterization skills in 2 female children with spina bifida. Based on a task analysis, the children were taught to perform on a doll each of the components of preparation, and, using a mirror to locate the urinary meatus, to insert and remove the catheter and to clean-up. Before, during, and after training, the children's performance of the skills on the doll and on themselves was assessed. Results of a multiple baseline design across subjects and skill components showed that doll training facilitated the children's acquisition of self-catheterization skills.

Enhancing child compliance with nebulized respiratory treatment. A case study

A 2.7-year-old developmentally delayed boy diagnosed as having chronic lung disease, severe hyaline membrane disease, and persistent pulmonary hypertension with interstitial emphysema was referred in hopes of modifying his refusal to wear a mask during nebulized administrations of Chromolyn. The child was prescribed four 20-minute nebulized treatments daily but resisted treatment and removed the mask by turning his head and pushing the mask away with his hands. A procedure was implemented to gradually teach the child that turning his head and pushing the mask would not result in mask removal, and that by wearing the mask he would receive positive attention. By the end of treatment, the child was consistently wearing his mask for the required 20-minute intervals. Follow-up at 3 months confirmed maintenance of treatment effects.

Training parents to become better behavior managers. The need for a competency-based approach

Seven parents, each with a clinic-referred noncompliant child, participated in a 6-week group training program designed to teach instruction-giving and time-out skills. A didactic training format (lectures and modeling) was employed in the first three weekly sessions. The final three sessions involved competency-based instruction, during which parents had to demonstrate skills to a criterion level in order to complete training. A multiple baseline design across targeted skill domains was used to examine whether didactic training (with and without supplemental competency-based instruction), resulted in skill proficiency. Skill acquisition was assessed through simulations with adult confederates and the index child prior to training, at the conclusion of the didactic component, and following competency-based instruction. Parents' reports of the child's compliance with parental requests at home, the child's overall adjustment, and the degree of parental satisfaction with each training component were also obtained. In addition, 6-and 12-week follow-up assessments were completed. Results showed that didactic training alone was insufficient to promote skill acquisition to mastery criterion in each case. Following competency-based instruction, however, six of the seven parents achieved 90% skill proficiency with both targeted procedures. Acquired skills were maintained above baseline levels at 6- and 12-week follow-ups. Skill acquisition was typically associated with positive changes in all self-report measures. Results suggest that a group parent training approach to skill acquisition should include a competency-based curriculum along with direct observation outcome measures of targeted parent behaviors.

Communication skills training for parents: experimental and social validation

Coordination of professional services of behalf of children often hinges on the involvement of informed parents. The purposes of this study were to identify and experimentally and socially validate skills required of parents for effective communication with professionals. Target skills were identified on the basis of judges' social validation ratings of (a) sample interactions between parents and professionals and (b) the behaviors comprising a resultant task analysis. Eight parents were then trained in these skills via an instructional package. Results of a multiple baseline design across subjects and grouped skill domains showed that each parent acquired the targeted skills during simulated conferences and that correct responding usually generalized to actual conferences. Independent judges validated training outcomes, and participating parents indicated satisfaction with the curriculum.

Behavioral management of oral medication administration difficulties among children: a review of literature with case illustrations

Nonacceptance of prescribed oral medications among young children hinders medical treatment. The literature pertaining to teaching children how to swallow pills or capsules is reviewed. In addition, a multiple case study demonstrating the efficacy of a brief, easy-to-implement procedure designed to promote capsule acceptance is presented. In this study, two four-year-old children diagnosed to have chronic illnesses participated. In Case 1, use of verbal instruction, modeling, shaping, and contingent reinforcement resulted in the rapid acquisition of capsule swallowing skills. In Case 2, these training procedures, in combination with physical guidance contingent upon noncompliance, successfully produced repeated acceptance of medication by a child who had refused to swallow capsules. In both cases, compliance has been maintained for at least six months.

Assessment and treatment of multiple behavior problems exhibited by a profoundly retarded adolescent

The severe aggression and noncompliance of a profoundly retarded blind male were subjected to extensive behavioral assessment in order to identify controlling variables. The assessment, conducted across settings and therapists, suggested that these inappropriate behaviors functioned to avoid or terminate nonpreferred activities. Intervention consisted of manual guidance when there was noncompliance with instructions and edible reinforcement upon compliance; there were no direct contingencies for the inappropriate behaviors. Treatment procedures were implemented in a multiple baseline design across therapists and settings. Results show that the intervention consistently increased compliance, with concurrent decreases in inappropriate behaviors. Edible reinforcement and neuroleptic medication were withdrawn systematically with no loss of therapeutic gains. Family members and school personnel were trained to use the intervention procedures. Results are discussed in terms of functional assessment, response covariation, compliance training, parent and staff training, and behavioral assessment of the effects of neuroleptic medication.

Experimental analysis of response covariation among compliant and inappropriate behaviors

Reliable changes in a variety of behaviors, or classes of behaviors, when only one is manipulated experimentally, have demonstrated that even topographically dissimilar responses can be functionally related. We investigated such a relationship between topographically different child behaviors (compliance and inappropriate activities) by using a methodology that tests for response covariation. Five conditions were provided to sequentially increase and decrease first one and then the other of these behaviors, with the degree of covariation between the two behaviors (i.e., the relationship between changes in the targeted and nontargeted behaviors) being the finding of interest. Results showed that, regardless of the intervention used, the behavior targeted, or the direction manipulated, the nontargeted behavior reliably covaried inversely with the targeted one. The findings have immediate relevance to the clinical treatment of multiple behavior problems exhibited by children. Furthermore, the study of relationships between responses and the processes underlying these relationships can have important implications for understanding the complexity characteristic of human behavior not yet analyzed by behavioral research.

Residents' knowledge of behavioral pediatrics

Four groups of residency programs (4433 residents) were compared regarding performance on the In-Training Exam of the American Board of Pediatrics and a 30-item addendum assessing behavioral knowledge: 10 programs funded to provide mandatory training, 6 not funded but requiring training, 4 control programs not requiring training but participating in an evaluation of behavioral training, and all other programs (221) whose residents took the exam. Three measures were calculated for each resident: percent correct on "organic" items; percent correct on "behavioral" items; and a ratio (behavioral to organic). Moderate positive correlations were found between organic and behavioral scores. There were no significant differences in organic performance related to program type. Ratio scores were higher for PL-1-funded residents than for any other PL-1 group. For PL-2s, Funded, Not Funded, and Control residents performed better than the All Other group. By the 3rd year, Funded residents performed better than All Other residents; Not Funded and Control scores fell in between. These data suggest that: (1) behavioral knowledge is only moderately related to organic knowledge; (2) requiring behavioral training increases behavioral knowledge but does not decrease the level of organic knowledge; and (3) funded programs attract residents more knowledgeable about behavior who, during their training, remain more knowledgeable than residents in programs not participating in an evaluation of behavioral training.

Behavior analysis, program development, and transfer of control in the treatment of self-injury

This case study illustrates an empirical approach to the diagnosis, treatment, and controlled follow-up of self-injurious clients. Following an assessment period, during which environmental factors associated with a severely retarded adolescent's self-injury were identified, the contingent application of protective equipment was combined with a differential reinforcement procedure (DRO) and implemented in a multiple baseline design across two hospital settings. Results showed a marked decrease in the rate of self-injury. Upon discharge from the hospital, the program was successfully replicated at the adolescent's residential center, again using a multiple baseline design across settings.

Training professionals to record proceedings of interdisciplinary team conferences

Two experiments were conducted to assess the effectiveness of an instructional program in preparing staff and trainees at a university affiliated facility (UAF) to record proceedings of interdisciplinary team conferences. Training consisted of a self-instructional manual supplemented by a narrated videotape of a typical interdisciplinary case conference. Data were collected on the extent to which trainees correctly completed individual educational plan work sheets based on conference proceedings as a function of training. Findings of both experiments showed that the training program resulted in rapid acquisition of skills required to record team proceedings.

A preliminary investigation of three issues pertaining to a common behavioral treatment for nocturnal enuresis

Two adolescent brothers exhibiting nocturnal enuresis since birth participated in this multiple case study examining the successful application of a modified alarm and pad procedure with a deaf youth and the generalization of effects to an initially untreated, non-hearing impaired sibling. A description of the treatment program and the explicit statement of an avoidance contingency prior to intervention resulted in a rapid and marked increase in percentage of dry nights in both cases, with further increases observed following implementation of an alarm and pad plus accident correction procedure in conjunction with self-monitoring. Treatment gains were maintained at a 10-month follow-up.

Current status of behavioral pediatric training for general pediatric residents: a study of 11 funded programs

The W. T. Grant Foundation has funded training in behavioral pediatrics for pediatric residents at 11 medical centers. The approaches toward training taken by the 11 funded programs, based on information systematically collected by interviews conducted with departmental chairmen, faculty, and residents during a program visit to each medical center, are described. No single training site emerged as optimal for teaching behavioral pediatrics, although linking such teaching to a "low priority" setting was an educational obstacle. A serious problem in many programs was the lack of ongoing research in behavioral pediatrics. Success in teaching behavioral pediatrics was dependent upon faculty support and a mandatory experience in behavioral pediatrics for all residents.

Assessment and reduction of food stealing in Prader-Willi children

A common behavior problem among Prader-Willi children is inappropriate foraging for food. Theft and subsequent consumption often go undetected and contribute to morbid obesity in many of these individuals. In this study an observational methodology was developed to assess food stealing in two children with Prader-Willi syndrome. The children were observed to steal food at a high rates under baseline conditions in three hospital settings. Subsequent treatment, based on differential reinforcement of other behavior (DRO), consisted of reinforcement of nonstealing at the end of progressively lengthening intervals, and was implemented in multiple baseline fashion across both subjects and settings. Results showed that both subjects' stealing rapidly ceased in treated settings, but failed to show generalization to untreated settings. Follow-up data collected in one setting after termination of active intervention reflected continued nonoccurrence of food stealing, although long-term weight data were not encouraging. Results are discussed in terms of their methodological contribution to the study and treatment of Prader-Willi syndrome.

The class specific effects of compliance training with "do" and "don't" requests: analogue analysis and classroom application

Two experiments are reported in which the relationship between compliance with "do" and "don't" requests was examined with developmentally disabled children. In Experiment 1, a multiple baseline design across subjects with counterbalanced treatment conditions was used to evaluate a compliance training program composed of four phases: (a) baseline, during which no consequences were delivered for compliance, (b) reinforcement for compliance with one targeted "do" request, (c) reinforcement for compliance with one targeted "don't" request, and (d) follow-up with reinforcement on a variable ratio schedule for compliance with any "do" or "don't" request. Results of probes conducted before and after training within each condition indicated that generalized compliance occurred only with requests of the same type as the target exemplar ("do" or "don't"). In Experiment 2, these results were replicated in a classroom setting. Following collection of baseline probe data on student compliance, a teacher training program was successfully implemented to increase reinforcement of compliance first with one "do" and subsequently with one "don't" request of a target student. Results of multiple baseline probes across "do" and "don't" requests indicated that the teacher generalized and maintained reinforcement of compliance with other requests of the same type and to other students, with a resulting increase in student compliance with the type of requests reinforced. The impact of treatment on both teacher and student behavior was socially validated via consumer ratings. Implications of these findings with respect to response class formation and compliance training programs are discussed.

The Dubowitz syndrome: the psychological status of ten cases at follow-up

We report the psychological status of ten people with the Dubowitz syndrome, an autosomal recessive condition characterized by intrauterine and postnatal growth retardation, microcephaly, and high-pitched hoarse voice. Results indicate that the level of intellectual functioning among children with Dubowitz syndrome varies from severe retardation to average intelligence. Our patients have delays in the development of memory, reasoning, expressive vocabulary, fine motor development, and receptive vocabulary, in order of ascending frequency. Data regarding growth status, level of adaptive functioning, and presence of behavioral deficits are also presented.

Neuroblastoma, Ganglioneuroma and Fibroneuroma in a Stillborn Fetus

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