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Moynihan KM, Dorste A, Alizadeh F, Phelps K, Barreto JA, Kolwaite AR, Merlocco A, Barbaro RP, Chan T, Thiagarajan RR. Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature. Crit Care Med 2023; 51:843-860. [PMID: 36975216 DOI: 10.1097/ccm.0000000000005866] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes. DATA SOURCES PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 to January 2023, examining socioeconomic status (SES), race, ethnicity, hospital and ECMO program characteristics, transport, and geographic location (context) with utilization and outcomes (concept) in ECMO patients (population). STUDY SELECTION Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review extension. Two reviewers independently evaluated abstracts and full text of identified publications. Exclusion criteria included non-English, unavailable, less than 40 patients, and periprocedural or mixed mechanical support. DATA EXTRACTION Content analysis used a standardized data extraction tool and inductive thematic analysis for author-proposed mediators of disparities. Risk of bias was assessed using the Quality in Prognosis Studies tool. DATA SYNTHESIS Of 8,214 citations screened, 219 studies were identified. Primary analysis focuses on 148 (68%) including race/ethnicity/SES/payer variables including investigation of ECMO outcomes 114 (77%) and utilization 43 (29%). SDoH were the primary predictor in 15 (10%). Overall quality and methodologic rigor was poor with advanced statistics in 7%. Direction of associations between ECMO outcomes or utilization according to race, ethnicity, SES, or payer varied. In 38% adverse outcomes or lower use was reported in underrepresented, under-resourced or diverse populations, while improved outcomes or greater use were observed in these populations in 7%, and 55% had no statistically significant result. Only 26 studies (18%) discussed mechanistic drivers of disparities, primarily focusing on individual- and hospital-level rather than systemic/structural factors. CONCLUSIONS Associations between ECMO utilization and outcomes with SDoH are inconsistent, complicated by population heterogeneity and analytic shortcomings with limited consideration of systemic contributors. Findings and research gaps have implications for measuring, analyzing, and interpreting SDoH in ECMO research and healthcare.
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Affiliation(s)
- Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Anna Dorste
- Medical Library, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kayla Phelps
- Department of Pediatrics, Children's Hospital New Orleans, Louisiana State University, New Orleans, LA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Amy R Kolwaite
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Anthony Merlocco
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Ryan P Barbaro
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Titus Chan
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Ravi R Thiagarajan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA
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Lorts A, Conway J, Schweiger M, Adachi I, Amdani S, Auerbach SR, Barr C, Bleiweis MS, Blume ED, Burstein DS, Cedars A, Chen S, Cousino-Hood MK, Daly KP, Danziger-Isakov LA, Dubyk N, Eastaugh L, Friedland-Little J, Gajarski R, Hasan A, Hawkins B, Jeewa A, Kindel SJ, Kogaki S, Lantz J, Law SP, Maeda K, Mathew J, May LJ, Miera O, Murray J, Niebler RA, O'Connor MJ, Özbaran M, Peng DM, Philip J, Reardon LC, Rosenthal DN, Rossano J, Salazar L, Schumacher KR, Simpson KE, Stiller B, Sutcliffe DL, Tunuguntla H, VanderPluym C, Villa C, Wearden PD, Zafar F, Zimpfer D, Zinn MD, Morales IRD, Cowger J, Buchholz H, Amodeo A. ISHLT consensus statement for the selection and management of pediatric and congenital heart disease patients on ventricular assist devices Endorsed by the American Heart Association. J Heart Lung Transplant 2021; 40:709-732. [PMID: 34193359 DOI: 10.1016/j.healun.2021.04.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 01/17/2023] Open
Affiliation(s)
- Angela Lorts
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio.
| | | | - Martin Schweiger
- Universitäts-Kinderspitals Zürich - Herzchirurgie, Zurich, Switzerland
| | - Iki Adachi
- Texas Children's Hospital, Houston, Texas
| | | | - Scott R Auerbach
- Anschutz Medical Campus, Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado
| | - Charlotte Barr
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | - Mark S Bleiweis
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | | | - Ari Cedars
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sharon Chen
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | | | - Kevin P Daly
- Boston Children's Hospital, Boston, Massachusetts
| | - Lara A Danziger-Isakov
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Nicole Dubyk
- Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Lucas Eastaugh
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Asif Hasan
- Freeman Hospital, Newcastle upon Tyne, UK
| | - Beth Hawkins
- Boston Children's Hospital, Boston, Massachusetts
| | - Aamir Jeewa
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Steven J Kindel
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | - Jodie Lantz
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sabrina P Law
- Morgan Stanley Children's Hospital of New York Presbyterian, New York, New York
| | - Katsuhide Maeda
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Jacob Mathew
- The Royal Children's Hospital, Victoria Melbourne, Australia
| | | | | | - Jenna Murray
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Robert A Niebler
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Winscoin
| | | | | | - David M Peng
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Joseph Philip
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | | | - David N Rosenthal
- Stanford Children's Health and Lucile Packard Children's Hospital, Palo Alto, California
| | - Joseph Rossano
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Kurt R Schumacher
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | | | - David L Sutcliffe
- Children's Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Chet Villa
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | | | - Matthew D Zinn
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Aguayo E, Kwon OJ, Dobaria V, Sanaiha Y, Hadaya J, Sareh S, Huynh A, Benharash P. Impact of interhospital transfer on clinical outcomes and costs of extracorporeal life support. Surgery 2020; 168:193-197. [PMID: 32507298 DOI: 10.1016/j.surg.2020.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/20/2020] [Accepted: 04/06/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The impact of interhospital transfers for extracorporeal life support have not been studied in large datasets. The present study sought to determine the impact of such patient transfers on survival, complications, and hospitalization costs. METHODS The 2010 to 2016 database of the National Inpatient Sample was used to identify all adults who underwent extracorporeal life support. Patients were categorized based on whether or not they were transferred to another facility. Trend analysis and multivariable models were used to characterize the impact of inter hospital transfer on in-hospital mortality, complications, duration of stay, and costs. RESULTS Of an estimated 29,298 extracorporeal life support hospitalizations during the study period, 36.8% were transferred from an outside facility. Extracorporeal life support hospitalizations experienced a 7-fold increase with no difference in mortality between transferred and not transferred cohorts in 2016 (4.79% vs 4.79%, P = .97). Mortality rates were less for patients transferred to high volume centers compared to low volume hospitals (48.7% vs 51.6%, P < .001). Transfer to a low volume hospital for cardiogenic shock was associated with greater odds of mortality (adjusted odds Rratio: 2.25, confidence interval 1.01-5.03). CONCLUSION Utilization of extracorporeal life support in both transferred and not transferred patients has statistically significantly increased with a decrement in mortality for those transferred. Survival in the transferred cohort is strongly associated with extracorporeal life support procedure volume of the center and this must be taken into account when considering extracorporeal life support transfer.
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Affiliation(s)
- Esteban Aguayo
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Oh Jin Kwon
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Sohail Sareh
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA; Department of Surgery, Harbor University of California-Los Angeles, Torrance, CA
| | - Ashley Huynh
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at University of California, Los Angeles, CA; Division of Cardiac Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA.
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Marcos-Alonso S, Gil N, García-Guereta L, Albert D, Tejero MÁ, Perez-Villa F, Gómez Bueno M, Blasco Peiró T, Cano A, Díaz Molina B, Rangel Sousa D. Impact of mechanical circulatory support on survival in pediatric heart transplantation. Pediatr Transplant 2020; 24:e13707. [PMID: 32212306 DOI: 10.1111/petr.13707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/24/2020] [Accepted: 03/05/2020] [Indexed: 11/29/2022]
Abstract
Evidence on the impact of MCS on pediatric heart transplant survival is still scarce related to congenital heart disease patients including univentricular physiology as well as the risk factors for complications. We performed a retrospective review of all urgent pediatric (aged ≤16 years) HT from 2004 to 2014 in the Spanish Pediatric Heart Transplant Registry Group. Patients were stratified into two groups: urgent 0 (MCS at HT) and urgent 1 (non-MCS at HT). The primary outcome measure was post-transplant survival; secondary outcome measures were complications and absence of infections and rejection during the first post-transplant year. One hundred twenty-one pediatric patients underwent urgent HT, 58 (47.9%) urgent 0 and 63 (52%) urgent 1. There were 30 (24.8%) deaths: 12 in the urgent 0 group and 18 in the urgent 1 group, P = n.s. Regarding the type of MCS, patients on ECMO had the highest rate of complications (80%) and mortality (40%). Patients in the urgent 1 group showed a higher risk of hospital re-admission for infection during the first year after transplantation (OR 2.31 [1.1-4.82]), P = .025. We did not identify a risk factor for mortality. MCS does not impact negatively on survival after HT. However, there is a significant increase in 30-day and 1-year mortality and complications in ECMO patients compared with VAD patients. Infants, congenital heart disease, and PediMACS were not found to be risk factors for mortality.
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Affiliation(s)
- Sonia Marcos-Alonso
- Pediatric Cardiology and Congenital Heart Disease Unit, Pediatric Department, Hospital Materno Infantil, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Nuria Gil
- Pediatric Cardiology and Congenital Heart Disease Unit, Pediatric Department, Hospital Gregorio Marañón, Madrid, Spain
| | - Luis García-Guereta
- Pediatric Cardiology and Congenital Heart Disease Unit, Pediatric Department, Hospital La Paz, Madrid, Spain
| | - Dimpna Albert
- Pediatric Cardiology and Congenital Heart Disease Unit, Pediatric Department, Hospital Vall d´Hebrón, Barcelona, Spain
| | - María Ángeles Tejero
- Pediatric Cardiology and Congenital Heart Disease Unit, Pediatric Department, Hospital Reina Sofía, Córdoba, Spain
| | - Félix Perez-Villa
- Cardiology Department, Hospital Clinic i Provincial, Barcelona, Spain
| | | | | | - Ana Cano
- Pediatric Cardiology and Congenital Heart Disease Unit, Pediatric Department, Hospital La Fe, Valencia, Spain
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Barron LC, Haas N, Hagl C, Schulze-Neick I, Ulrich S, Lehner A, Heinen F, Weinberger R, Rosenthal L, Gerstl L, Dalla-Pozza R. Motor outcome, executive functioning, and health-related quality of life of children, adolescents, and young adults after ventricular assist device and heart transplantation. Pediatr Transplant 2020; 24:e13631. [PMID: 31885156 DOI: 10.1111/petr.13631] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 10/10/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the current study is to measure long-term executive function, motor outcome, and QoL in children, adolescents, and young adults after VAD and Htx. METHODS Patients were examined during routine follow-up. Investigation tools were used as follows: Examination for MND of motor outcomes, Epitrack® for attention and executive functioning, and Kidscreen-52 and EQ-5D-5L questionnaires for QoL. Additional data were retrospectively obtained by an analysis of patient medical records. RESULTS Out of 145 heart transplant recipients at the department of pediatric cardiology of the University Hospital Munich, 39 were implanted with a VAD between 1992 and 2016. Seventeen (43.6%) patients died before or after Htx; 22 (56.4%) patients were included in our study. Mean age at transplant was 9.52 years (range: 0.58-24.39 years, median 9), and the mean follow-up time after Htx was 6.18 years (range: 0.05-14.60 years, median 5.82). MND examination could be performed in 13 patients (normal MND: n = 11, simple MND: n = 1, complex MND: n = 1). Executive functioning was tested in 15 patients. Two (13.3%) patients had good results, six (40%) average results, three (20%) borderline results, and four (26.7%) impaired results. QoL (Kidscreen n = 7, EQ-5D-5L n = 8) was similar to a healthy German population. CONCLUSION Motor outcome, executive functioning and QoL in survivors of VAD bridging therapy and Htx can be good, though underlying diseases and therapies are associated with a high risk of cerebral ischemic or hemorrhagic complications.
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Affiliation(s)
- Lucie-Charlotte Barron
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
| | - Nikolaus Haas
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department for Cardiac Surgery, LMU Munich, Munich, Germany
| | - Ingram Schulze-Neick
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
| | - Sarah Ulrich
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
| | - Anja Lehner
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
| | - Florian Heinen
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children`s Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Raphael Weinberger
- Division of Epidemiology, Institute of Social Paediatrics and Adolescent Medicine, LMU Munich, Munich, Germany
| | - Lale Rosenthal
- Department for Cardiac Surgery, LMU Munich, Munich, Germany
| | - Lucia Gerstl
- Department of Paediatric Neurology and Developmental Medicine, Dr. von Hauner Children`s Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Robert Dalla-Pozza
- Department of Paediatric Cardiology and Paediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany
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Sims T, Tumin D, Hayes D, Tobias JD. Age-Dependent Impact of Pre-Transplant Intensive Care Unit Stay on Mortality in Heart Transplant Recipients. Cardiol Res 2019; 10:157-164. [PMID: 31236178 PMCID: PMC6575112 DOI: 10.14740/cr870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 05/30/2019] [Indexed: 11/19/2022] Open
Abstract
Background Heart transplantation (HTx) is a treatment option for refractory end-stage heart failure. Severe illness requiring pre-transplant intensive care unit (ICU) stay may be a risk factor for diminished post-transplant survival, but this association is surprisingly inconsistent in recent studies. To clarify the significance of ICU stay as a risk factor for heart transplant outcomes, we aimed to define if patient age was a factor in which ICU stay was predictive of survival after HTx. Methods De-identified data were obtained on isolated first-time HTx performed during the years 2006 - 2015 from the UNOS Registry. Nine age groups were defined. The primary outcome was 1-year post-transplant mortality. Cox proportional hazard regression estimated unadjusted and adjusted hazard ratio (HR) associated with pre-transplant ICU stay in each age group. Results The analysis included 19,508 patients (9% deceased within 1 year). In the overall cohort, pre-transplant ICU stay was associated with increased hazard of 1-year mortality (HR = 1.3; 95% confidence interval (CI): 1.2 - 1.4; P < 0.001); but further univariate analysis showed a greater hazard of 1-year mortality associated with ICU stay in infants (HR = 2.2; 95% CI: 1.5 - 3.2; P < 0.001). However, the adjusted analysis found that adults ages 40 - 49 had the highest statistically significant hazard of 1-year mortality (HR = 1.5; 95% CI: 1.1 - 2.1; P = 0.011). Conclusions Our study established age variation in the association between ICU stay and survival after HTx, with this association being strongest among adults, 40 to 49 years of age, undergoing HTx. Previous data suggesting decreased survival in infants may be related to the increased use of extracorporeal membrane oxygenation as a mechanical cardiac assist rather than ventricular assist devices.
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Affiliation(s)
- Trent Sims
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Don Hayes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pulmonary Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Nasr VG, Twite MD, Walker SG, Kussman BD, Motta P, Mittnacht AJC, Mossad EB. Selected 2017 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2018; 32:1546-1555. [PMID: 29699846 DOI: 10.1053/j.jvca.2018.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Vivian G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Mark D Twite
- Department of Anesthesiology, University of Colorado and Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Scott G Walker
- Department of Anesthesiology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Barry D Kussman
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Pablo Motta
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alexander J C Mittnacht
- Department of Anesthesiology, Perioperative and Pain Medicine, the Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Emad B Mossad
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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