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Tavazzi G, Dammassa V, Colombo CNJ, Arbustini E, Castelein T, Balik M, Vandenbriele C. Mechanical circulatory support in ventricular arrhythmias. Front Cardiovasc Med 2022; 9:987008. [PMID: 36304552 PMCID: PMC9593033 DOI: 10.3389/fcvm.2022.987008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/15/2022] [Indexed: 11/27/2022] Open
Abstract
In atrial and ventricular tachyarrhythmias, reduced time for ventricular filling and loss of atrial contribution lead to a significant reduction in cardiac output, resulting in cardiogenic shock. This may also occur during catheter ablation in 11% of overall procedures and is associated with increased mortality. Managing cardiogenic shock and (supra) ventricular arrhythmias is particularly challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. The drop in native cardiac output during an arrhythmic storm can be partly covered by the insertion of percutaneous mechanical circulatory support (MCS) devices guaranteeing end-organ perfusion. This provides physicians a time window of stability to investigate the underlying cause of arrhythmia and allow proper therapeutic interventions (e.g., percutaneous coronary intervention and catheter ablation). Temporary MCS can be used in the case of overt hemodynamic decompensation or as a “preemptive strategy” to avoid circulatory instability during interventional cardiology procedures in high-risk patients. Despite the increasing use of MCS in cardiogenic shock and during catheter ablation procedures, the recommendation level is still low, considering the lack of large observational studies and randomized clinical trials. Therefore, the evidence on the timing and the kinds of MCS devices has also scarcely been investigated. In the current review, we discuss the available evidence in the literature and gaps in knowledge on the use of MCS devices in the setting of ventricular arrhythmias and arrhythmic storms, including a specific focus on pathophysiology and related therapies.
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Affiliation(s)
- Guido Tavazzi
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy,Department of Anaesthesia, Intensive Care and Pain Therapy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy,*Correspondence: Guido Tavazzi
| | - Valentino Dammassa
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy,Adult Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | | | - Eloisa Arbustini
- Centre for Inherited Cardiovascular Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Thomas Castelein
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, First Medical Faculty and General University Hospital, Charles University in Prague, Prague, Czechia
| | - Christophe Vandenbriele
- Adult Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Swol J, Darocha T, Paal P, Brugger H, Podsiadło P, Kosiński S, Puślecki M, Ligowski M, Pasquier M. Extracorporeal Life Support in Accidental Hypothermia with Cardiac Arrest-A Narrative Review. ASAIO J 2022; 68:153-162. [PMID: 34261875 PMCID: PMC8797003 DOI: 10.1097/mat.0000000000001518] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Severely hypothermic patients, especially suffering cardiac arrest, require highly specialized treatment. The most common problems affecting the recognition and treatment seem to be awareness, logistics, and proper planning. In severe hypothermia, pathophysiologic changes occur in the cardiovascular system leading to dysrhythmias, decreased cardiac output, decreased central nervous system electrical activity, cold diuresis, and noncardiogenic pulmonary edema. Cardiac arrest, multiple organ dysfunction, and refractory vasoplegia are indicative of profound hypothermia. The aim of these narrative reviews is to describe the peculiar pathophysiology of patients suffering cardiac arrest from accidental hypothermia. We describe the good chances of neurologic recovery in certain circumstances, even in patients presenting with unwitnessed cardiac arrest, asystole, and the absence of bystander cardiopulmonary resuscitation. Guidance on patient selection, prognostication, and treatment, including extracorporeal life support, is given.
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Affiliation(s)
- Justyna Swol
- From the Deparment of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Tomasz Darocha
- Department of Anesthesiology and Intensive Care, Severe Accidental Hypothermia Center, Medical University of Silesia, Katowice, Poland
| | - Peter Paal
- Department of Anesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - Paweł Podsiadło
- Department of Emergency Medicine, Jan Kochanowski University, Kielce, Poland
| | - Sylweriusz Kosiński
- Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Puślecki
- Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland
- Departmentf Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Ligowski
- Departmentf Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
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3
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Bjertnæs LJ, Hindberg K, Næsheim TO, Suborov EV, Reierth E, Kirov MY, Lebedinskii KM, Tveita T. Rewarming From Hypothermic Cardiac Arrest Applying Extracorporeal Life Support: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:641633. [PMID: 34055829 PMCID: PMC8155640 DOI: 10.3389/fmed.2021.641633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/04/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: This systematic review and meta-analysis aims at comparing outcomes of rewarming after accidental hypothermic cardiac arrest (HCA) with cardiopulmonary bypass (CPB) or/and extracorporeal membrane oxygenation (ECMO). Material and Methods: Literature searches were limited to references with an abstract in English, French or German. Additionally, we searched reference lists of included papers. Primary outcome was survival to hospital discharge. We assessed neurological outcome, differences in relative risks (RR) of surviving, as related to the applied rewarming technique, sex, asphyxia, and witnessed or unwitnessed HCA. We calculated hypothermia outcome prediction probability score after extracorporeal life support (HOPE) in patients in whom we found individual data. P < 0.05 considered significant. Results: Twenty-three case observation studies comprising 464 patients were included in a meta-analysis comparing outcomes of rewarming with CPB or/and ECMO. One-hundred-and-seventy-two patients (37%) survived to hospital discharge, 76 of 245 (31%) after CPB and 96 of 219 (44 %) after ECMO; 87 and 75%, respectively, had good neurological outcomes. Overall chance of surviving was 41% higher (P = 0.005) with ECMO as compared with CPB. A man and a woman had 46% (P = 0.043) and 31% (P = 0.115) higher chance, respectively, of surviving with ECMO as compared with CPB. Avalanche victims had the lowest chance of surviving, followed by drowning and people losing consciousness in cold environments. Assessed by logistic regression, asphyxia, unwitnessed HCA, male sex, high initial body temperature, low pH and high serum potassium (s-K+) levels were associated with reduced chance of surviving. In patients displaying individual data, overall mean predictive surviving probability (HOPE score; n = 134) was 33.9 ± 33.6% with no significant difference between ECMO and CPB-treated patients. We also surveyed 80 case reports with 96 victims of HCA, who underwent resuscitation with CPB or ECMO, without including them in the meta-analysis. Conclusions: The chance of surviving was significantly higher after rewarming with ECMO, as compared to CPB, and in patients with witnessed compared to unwitnessed HCA. Avalanche victims had the lowest probability of surviving. Male sex, high initial body temperature, low pH, and high s-K+ were factors associated with low surviving chances.
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Affiliation(s)
- Lars J. Bjertnæs
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Kristian Hindberg
- K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Torvind O. Næsheim
- Cardiovascular Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Evgeny V. Suborov
- The Nikiforov Russian Federation Center of Emergency and Radiation Medicine, St. Petersburg, Russia
| | - Eirik Reierth
- Science and Health Library, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantin M. Lebedinskii
- Department of Anesthesiology and Intensive Care, North-Western State Medical University Named After I. I. Mechnikov, St. Petersburg, Russia
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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Balik M, Porizka M, Matousek V, Brestovansky P, Svobodova E, Flaksa M, Rulisek J, Mlejnsky F, Hodkova G, Grus T, Vobruba V, Belohlavek J. Management of accidental hypothermia: an established extracorporeal membrane oxygenation centre experience. Perfusion 2019; 34:74-81. [DOI: 10.1177/0267659119830551] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Data on management of severe accidental hypothermia published from an established high-volume extracorporeal membrane oxygenation centre are scarce. Methods: A total of 28 patients with intravesical temperature lower than 28°C on admission were either treated with veno-arterial extracorporeal membrane oxygenation or rewarmed conservatively. Results: A total of 10 patients rewarmed on veno-arterial extracorporeal membrane oxygenation (age: 37 ± 12.6 years) and 18 conservatively (age: 55.2 ± 11.2 years) were collected over a course of 5 years. The dominant cause was alcohol intoxication with exposure to cold (39%), 12 patients were resuscitated prior to admission. The admission temperature in the extracorporeal membrane oxygenation group (23.8 ± 2.6°C) was lower than in the non–extracorporeal membrane oxygenation group (26.0 ± 1.5°C, p = 0.01). The peripheral percutaneous veno-arterial extracorporeal membrane oxygenation was always cannulated in malignant arrhythmias causing refractory cardiac arrest. The typical extracorporeal membrane oxygenation blood flow was 3-4 L/minute and sweep gas flow 2 L/minute, the median extracorporeal membrane oxygenation duration was 48.3 (28.1-86.7) hours. The median rates of rewarming did not differ (0.41 (0.35-0.7)°C/hour in extracorporeal membrane oxygenation and 0.77 (0.54-0.98)°C/hour in non–extracorporeal membrane oxygenation, p = 0.46) as well as the admission arterial lactate, pH and potassium. Their development was not different between the groups except for higher pH between the third and ninth hour of rewarming in the extracorporeal membrane oxygenation group. The hospital mortality was 10% in the extracorporeal membrane oxygenation group and 11.1% in the non–extracorporeal membrane oxygenation group with the median last Glasgow Coma Scale 15 and Cerebral Performance Score 1. Conclusion: Veno-arterial extracorporeal membrane oxygenation for severe hypothermia shows promising outcome data collected in an extracorporeal membrane oxygenation/extracorporeal cardiopulmonary resuscitation centre located in a European urban area. Except for presence of refractory cardiac arrest, the established hypothermia-related prognostic indicators did not differ between patients in need for extracorporeal membrane oxygenation and those rewarmed without extracorporeal membrane oxygenation.
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Affiliation(s)
- Martin Balik
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Michal Porizka
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Vojtech Matousek
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Petr Brestovansky
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Eva Svobodova
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Marek Flaksa
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Rulisek
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Frantisek Mlejnsky
- Perfusion Unit, Department of Cardiovascular Surgery, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Gabriela Hodkova
- Perfusion Unit, Department of Cardiovascular Surgery, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Tomas Grus
- Department of Cardiovascular Surgery, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Vaclav Vobruba
- Department of Pediatrics, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Belohlavek
- 2nd Department of Internal Medicine – Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
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Saczkowski RS, Brown DJ, Abu-Laban RB, Fradet G, Schulze CJ, Kuzak ND. Prediction and risk stratification of survival in accidental hypothermia requiring extracorporeal life support: An individual patient data meta-analysis. Resuscitation 2018; 127:51-57. [DOI: 10.1016/j.resuscitation.2018.03.028] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 10/17/2022]
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6
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El Sibai R, Bachir R, El Sayed M. Outcomes in Cardiogenic Shock Patients with Extracorporeal Membrane Oxygenation Use: A Matched Cohort Study in Hospitals across the United States. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2428648. [PMID: 29789779 PMCID: PMC5896328 DOI: 10.1155/2018/2428648] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/15/2017] [Accepted: 12/25/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND ECMO is increasingly used for patients with critical illnesses. This study examines ECMO use in patients with cardiogenic shock in US hospitals and associated outcomes (mortality, hospital length of stay, and total hospital charges). METHODS A matched cohort retrospective study was conducted using the 2013 Nationwide Emergency Department Sample. Cardiogenic shock visits were matched (1 : 1) and compared based on ECMO use. RESULTS Patients with ECMO (N = 802) were compared to patients without ECMO (N = 805). Mortality was higher in the ECMO group (48.9% versus 4.0%, p < 0.001). Visits with ECMO use also had higher average hospital charges ($580,065.8 versus $156,436.5, p < 0.001) and average hospital LOS (21.3 versus 11.6 days, p < 0.001). After adjusting for confounders, mortality (OR = 8.52 (95% CI: 2.84-25.58)) and charges (OR = 1.03 (95% CI: 1.02-1.05)) remained higher in the ECMO group, while LOS was similar (OR = 1.01 (95% CI: 0.99-1.02)). CONCLUSIONS Patients with cardiogenic shock who underwent ECMO had increased mortality and higher cost of care without significant increase in LOS when compared to patients with cardiogenic shock without ECMO use. Prospective evaluation of this observed association is needed to improve outcomes and resources' utilization further.
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Affiliation(s)
- Rayan El Sibai
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rana Bachir
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mazen El Sayed
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Emergency Medical Services and Prehospital Care Program, American University of Beirut Medical Center, Beirut, Lebanon
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7
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Muñoz J, Santa-Teresa P, Tomey MJ, Visedo LC, Keough E, Barrios JC, Sabell S, Morales A. Extracorporeal membrane oxygenation (ECMO) in adults with acute respiratory distress syndrome (ARDS). Heart Lung 2017; 46:100-105. [DOI: 10.1016/j.hrtlng.2017.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/04/2017] [Accepted: 01/06/2017] [Indexed: 01/19/2023]
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Orrego R, Díaz R. REANIMACIÓN CARDIOPULMONAR EXTRACORPÓREA: LA ÚLTIMA FRONTERA. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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9
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Mosier JM, Kelsey M, Raz Y, Gunnerson KJ, Meyer R, Hypes CD, Malo J, Whitmore SP, Spaite DW. Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:431. [PMID: 26672979 PMCID: PMC4699333 DOI: 10.1186/s13054-015-1155-7] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal life support that augments oxygenation, ventilation and/or cardiac output via cannulae connected to a circuit that pumps blood through an oxygenator and back into the patient. ECMO has been used for decades to support cardiopulmonary disease refractory to conventional therapy. While not robust, there are promising data for the use of ECMO in acute hypoxemic respiratory failure, cardiac arrest, and cardiogenic shock and the potential indications for ECMO continue to increase. This review discusses the existing literature on the potential use of ECMO in critically ill patients within the emergency department.
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Affiliation(s)
- Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA. .,Arizona Emergency Medicine Research Center, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA. .,Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85721, USA.
| | - Melissa Kelsey
- Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA
| | - Yuval Raz
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85721, USA
| | - Kyle J Gunnerson
- Division of Emergency Critical Care, Department of Emergency Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Robyn Meyer
- Division of Pediatric Intensive Care, Department of Pediatrics, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85721, USA
| | - Cameron D Hypes
- Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA.,Arizona Emergency Medicine Research Center, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA.,Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85721, USA
| | - Josh Malo
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85721, USA
| | - Sage P Whitmore
- Division of Emergency Critical Care, Department of Emergency Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA
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