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Papastefan ST, Alhajjat AM, Ott KC, Liesman DR, Langereis MM, Boat AC, Pombar XF, Kominiarek MA, Bowman RM, Shaaban AF. Fetal bradycardia in open versus fetoscopic prenatal repair of spina bifida. Prenat Diagn 2024. [PMID: 38877305 DOI: 10.1002/pd.6626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/27/2024] [Accepted: 06/08/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE To compare the occurrence of fetal bradycardia in open versus fetoscopic fetal spina bifida surgery. METHODS This is a single-institution retrospective cohort study of patients undergoing open (n = 25) or fetoscopic (n = 26) spina bifida repair between 2017 and 2022. From October 2017 to June 2020, spina bifida repairs were performed via an open classical hysterotomy, and from November 2020 to June 2022 fetoscopic repairs were performed following transition to this technique. Fetal heart rate (FHR) in beats per minute (bpm) was recorded via echocardiography every 15 min during the procedure. Cohort characteristics, fetal bradycardia and maternal physiologic parameters were compared between the groups. RESULTS Fetuses undergoing an open repair more frequently developed bradycardia defined as <110 bpm (32% vs. 3.8%, p = 0.008), and a trend was observed for FHR decreases more than 25 bpm from baseline (20% vs. 3.8%, p = 0.073). Profound bradycardia less than 80 bpm was rare, occurring in only three operations (two in open, one in fetoscopic repair) with two fetuses (one in each group) requiring emergency cesarean delivery. CONCLUSION When compared to open fetal surgery, fetal bradycardia occurred less frequently in fetoscopic surgery despite a significantly greater anesthetic exposure and the use of the intraamniotic carbon dioxide insufflation.
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Affiliation(s)
- Steven T Papastefan
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amir M Alhajjat
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katherine C Ott
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniel R Liesman
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Morgan M Langereis
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anne C Boat
- Division of Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xavier F Pombar
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA
| | - Michelle A Kominiarek
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robin M Bowman
- Division of Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Aimen F Shaaban
- Department of Surgery, The Chicago Institute for Fetal Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Obiyo LT, Tobes D, Cole NM. Anesthetic recommendations for maternal and fetal safety in nonobstetric surgery: a balancing act. Curr Opin Anaesthesiol 2024; 37:285-291. [PMID: 38390901 DOI: 10.1097/aco.0000000000001363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Nonobstetric surgery during pregnancy is associated with maternal and fetal risks. Several physiologic changes create unique challenges for anesthesiologists. This review highlights physiologic changes of pregnancy and presents clinical recommendations based on recent literature to guide anesthetic management for the pregnant patient undergoing nonobstetric surgery. RECENT FINDINGS Nearly every anesthetic technique has been safely used in pregnant patients. Although it is difficult to eliminate confounding factors, exposure to anesthetics could endanger fetal brain development. Perioperative fetal monitoring decisions require an obstetric consult based on anticipated maternal and fetal concerns. Given the limitations of fasting guidelines, bedside gastric ultrasound is useful in assessing aspiration risk in pregnant patients. Although there is concern about appropriateness of sugammadex for neuromuscular blockade reversal due its binding to progesterone, preliminary literature supports its safety. SUMMARY These recommendations will equip anesthesiologists to provide safe care for the pregnant patient and fetus undergoing nonobstetric surgery.
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Affiliation(s)
- Leziga T Obiyo
- Department of Anesthesia & Critical Care, University of Chicago, Chicago, Illinois, USA
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Tartaglia S, Zanfini BA, Gueli Alletti S, Draisci G, Lanzone A. The Importance of Fetoplacental Doppler Velocimetry for Fetal Surveillance During General Anesthesia for Non-obstetric Surgery. Cureus 2024; 16:e52382. [PMID: 38230384 PMCID: PMC10790955 DOI: 10.7759/cureus.52382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 01/18/2024] Open
Abstract
Fetal heart rate monitoring during general anesthesia for non-obstetric surgery at viable gestational ages is recommended to evaluate fetal well-being during the intervention. Alteration induced by anesthetic drugs could mimic fetal acute hypoxia, leading to pointless Cesarean sections. We report a case of a pregnant woman in the third trimester undergoing neurosurgical surgery. The continuous heart rate registration showed a non-reassuring pattern, potentially inducing the multidisciplinary team to expedite the delivery. The seriate fetoplacental Doppler evaluations were reassuring about normal fetal conditions, suggesting that ultrasound surveillance could be more reliable than intraoperative heart rate monitoring.
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Affiliation(s)
- Silvio Tartaglia
- Dipartimento di Scienza Della Salute Della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, ITA
| | - Bruno A Zanfini
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario Agostino Gemelli IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, ITA
| | - Salvatore Gueli Alletti
- Dipartimento di Scienza Della Salute Della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, ITA
| | - Gaetano Draisci
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario Agostino Gemelli IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, ITA
| | - Antonio Lanzone
- Dipartimento di Scienza Della Salute Della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, ITA
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Ruegg L, Vonzun L, Latal B, Moehrlen U, Mazzone L, Meuli M, Krähenmann F, Ochsenbein-Kölble N. Impact on postoperative, neonatal and 2-year neurodevelopmental outcomes of UA-AREDF during and after fetal spina bifida repair. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:734-739. [PMID: 36357943 DOI: 10.1002/uog.26118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Absent or reversed end-diastolic flow (AREDF) in the umbilical artery (UA) on Doppler is a known phenomenon during fetal interventions, such as fetal open spina bifida (OSB) repair. We aimed to evaluate the clinical importance of these Doppler findings by investigating the impact of UA-AREDF on postoperative, neonatal and 2-year neurodevelopmental outcomes. METHODS This was a prospective study of pregnancies undergoing fetal OSB repair at the Zurich Center for Fetal Diagnosis and Therapy between 2010 and 2019. The group with UA-AREDF during or immediately after the intervention was compared to the group with normal UA Doppler. Primary endpoint was the FIGO scores of cardiotocography (CTG) 1, 2 and 6 h postoperatively and on day 1 after surgery. Secondary endpoints were the neonatal parameters and 2-year neurodevelopmental outcome assessed using the Bayley Scales of Infant and Toddler Development, Third Edition. RESULTS Data of 130 patients were analyzed. None of the fetuses had UA-AREDF before OSB repair. Normal UA Doppler was observed in 107 (82%) patients and UA-AREDF was observed in 23 (18%) during or immediately after OSB surgery. UA-AREDF was more often observed after version of the fetus (P = 0.045). Seventeen (13%) cases had absent end-diastolic flow (UA-AEDF) and six (5%) cases had reversed end-diastolic flow (UA-REDF). UA-AREDF disappeared in all 23 cases within the first day after OSB surgery. One-third of all CTGs were restricted in oscillation after surgery, but no significant difference in CTG 1, 2 and 6 h postoperatively or on the first postoperative day was found between the UA-AREDF and normal-Doppler groups (P > 0.05). Gestational age at delivery, UA pH, 5-min Apgar score and birth weight were comparable between the two groups, and there was no difference in the 2-year neurodevelopmental outcome (P > 0.05). The neonatal and 2-year neurodevelopmental outcomes also did not differ significantly between the UA-REDF and UA-AEDF groups. CONCLUSIONS Postoperative CTG abnormalities occur and recover at a similar rate in fetuses with transitory UA-AREDF and those with normal Doppler during fetal OSB repair. UA-AREDF during fetal OSB repair did not negatively influence postnatal or 2-year neurodevelopmental outcomes. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L Ruegg
- Department of Obstetrics, University Hospital of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - L Vonzun
- Department of Obstetrics, University Hospital of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - B Latal
- University of Zurich, Zurich, Switzerland
- Department of Neuropediatrics, University Children's Hospital Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - U Moehrlen
- University of Zurich, Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - L Mazzone
- University of Zurich, Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - M Meuli
- University of Zurich, Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
- Spina Bifida Center, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - F Krähenmann
- Department of Obstetrics, University Hospital of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
| | - N Ochsenbein-Kölble
- Department of Obstetrics, University Hospital of Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Zurich Center for Fetal Diagnosis and Therapy, University of Zurich, Zurich, Switzerland
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Pitfield AF, Bedard A, Bashir J, Bruce S, Augoustides JG, Cormican DS, Marchant BE, Fernando RJ. Anesthetic Management for Cardiac Surgery During Pregnancy Complicated by Postoperative Threatened Abortion. J Cardiothorac Vasc Anesth 2023; 37:158-166. [PMID: 36319562 DOI: 10.1053/j.jvca.2022.09.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Jamil Bashir
- University of British Columbia, Vancouver, BC, Canada
| | - Simon Bruce
- Department of Anesthesia, Providence Health Care, University of British Columbia, Vancouver, BC, Canada
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel S Cormican
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA
| | - Bryan E Marchant
- Department of Anesthesiology, Cardiothoracic and Critical Care Sections, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC.
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Sharma VJ, Arghami A, Pasupula DK, Haddad A, Ke JXC. Outcomes of Coronary Artery Bypass Grafting in Patients With Poor Myocardial Viability: A Systematic Review and Meta-Analysis of the Last Decade. Heart Lung Circ 2022; 31:916-923. [PMID: 35339371 DOI: 10.1016/j.hlc.2021.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/30/2021] [Accepted: 12/31/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Our objective is to assess whether the presence of myocardial viability is a predictor of mortality among patients undergoing coronary artery bypasss grafting (CABG) through a systematic review meta-analysis. METHODS Comprehensive review of EMBASE and PubMed in accordance with PRISMA guidelines, including studies of patients undergoing CABG with assessment of myocardial viability and recorded long-term mortality, age and sex. Studies were restricted to the last decade, and data were stratified by imaging modality (magnetic resonance imaging [MRI] or nuclear medicine). Random-effects model for assessing pooled effect, heterogeneity assessment using Chi-square and I2 statistics, publication bias assessed by funnel plots and Egger's test. RESULTS Meta-analysis of contemporary data (January 2010 to October 2020) yielded 3,621 manuscripts of which 92 were relevant, and 6 appropriate for inclusion with 993 patients. Pooled analysis showed that patients with non-viable myocardium undergoing CABG are at 1.34 times the risk of mortality compared to those with viable myocardium (95% CI 1.01-1.79, p=0.05). Subgroup analysis of the MRI or nuclear medicine modalities was not statistically significant and there was no confounding by age or sex in meta-regression. There was significant heterogeneity in imaging modality and diagnostic criteria, but heterogeneity between study findings was low with an I2 statistic of 29%. The risk of publication bias was moderate on the Newcastle-Ottawa Scale), but not statistically significant (Egger's Test coefficient=1.3, 95%CI -0.35-2.61, p=0.10). CONCLUSIONS There is a multitude of methods for assessing cardiac viability for coronary revascularisation surgery, making meta-analyses fraught with limitations. Our meta-analysis demonstrates that the finding of non-viable myocardium can not be used draw conclusions for risk assessment in coronary surgery.
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Affiliation(s)
- Varun J Sharma
- Department of Cardiac Surgery, Austin Health, Heidelberg, Melbourne, Vic, Australia; Department of Surgery (Austin Health), Melbourne Medical School, Heidelberg, Melbourne, Vic, Australia; Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA; Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Deepak Kumar Pasupula
- Department of Cardiology, MercyOne North Iowa Medical Center, Mason City, IA, USA; Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Abdullah Haddad
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Janny Xue Chen Ke
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Canada; Department of Anesthesia, Providence Health Care, Vancouver, Canada; Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada; Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
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Boere I, Lok C, Poortmans P, Koppert L, Painter R, Vd Heuvel-Eibrink MM, Amant F. Breast cancer during pregnancy: epidemiology, phenotypes, presentation during pregnancy and therapeutic modalities. Best Pract Res Clin Obstet Gynaecol 2022; 82:46-59. [PMID: 35644793 DOI: 10.1016/j.bpobgyn.2022.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/02/2022]
Abstract
Although it is uncommon in general, breast cancer is the most commonly diagnosed cancer during pregnancy. While treatment for pregnant patients should adhere to treatment guidelines for non-pregnant patients, there exist specific considerations concerning diagnosis, staging, oncological treatment, and obstetrical care. Imaging and staging are preferably performed using breast ultrasound and mammography. Other ionizing radiation imaging modalities, including computed tomography (CT) and Positron Emission Tomography/ Computed Tomography (PET/CT), can be selectively performed when the estimated benefit for the mother outweighs the risks to the foetus, e.g., when the results will change clinical management. MRI is appropriate to stage for distant disease on the indication. Breast cancer during pregnancy is less often hormone receptor-positive and more frequently triple-negative breast cancer compared to age-matched controls. The basic principle is that women should receive state-of-the-art oncological treatment without delay if possible and that the pregnancy should be maintained as long as possible. Treatment strategy should be multidisciplinary defined, carefully weighing the selection, sequence, and timing of treatment modalities depending on patient-, tumour-, and pregnancy-related characteristics, as well as patient preferences. Initiating cancer treatment during pregnancy often decreases the risks of early delivery and prematurity. Breast cancer surgery is possible during all trimesters. Radiotherapy is possible during pregnancy in the first half of pregnancy. Chemotherapy can be safely administered starting from 12 weeks of gestational age, but endocrine and HER2 targeted therapy are contraindicated throughout the whole pregnancy. Importantly, foetal growth should be monitored and long-term follow-up of the children is encouraged in dedicated centres.
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Affiliation(s)
- Ingrid Boere
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Christianne Lok
- Center for Gynecological Oncology Amsterdam (CGOA), Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Philip Poortmans
- Iridium Network and University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Linetta Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rebecca Painter
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Marry M Vd Heuvel-Eibrink
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Frederic Amant
- Center for Gynecological Oncology Amsterdam (CGOA), Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, the Netherlands; Gynecologic Oncology, UZ Leuven, Belgium
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Girnius A, Meng ML. Cardio-Obstetrics: A Review for the Cardiac Anesthesiologist. J Cardiothorac Vasc Anesth 2021; 35:3483-3488. [PMID: 34253444 PMCID: PMC8607550 DOI: 10.1053/j.jvca.2021.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/09/2021] [Indexed: 02/02/2023]
Affiliation(s)
- Andrea Girnius
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH
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