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Arnone MI, Sforza A, Carlino MV, Guarino M, Candido R, Bertolone D, Fucile I, De Luca N, Mancusi C. Assessment of E/A ratio helps emergency clinicians in the management of patients with acute dyspnea. Intern Emerg Med 2023; 18:1823-1830. [PMID: 37103762 PMCID: PMC10504390 DOI: 10.1007/s11739-023-03279-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
Acute dyspnea (AD) is one of the main reasons for admission to the Emergency Department (ED). In the last years integrated ultrasound examination (IUE) of lung, heart and inferior vena cava (IVC) has become an extension of clinical examination for a fast differential diagnosis. The aim of present study is to assess the feasibility and diagnostic accuracy of E/A ratio for diagnosing acute heart failure (aHF) in patients with acute dyspnea. We included 92 patients presenting to the ED of CTO Hospital in Naples (Italy) for AD. All patients underwent IUE of lung-heart-IVC with a portable ultrasound device. Left ventricle diastolic function was assessed using pulse wave doppler at the tips of the mitral valve and E wave velocity and E/A ratio were recorded. The FINAL diagnosis was determined by two expert reviewers: acute HF or non-acute HF (non-aHF). We used 2 × 2 contingency tables to analyze sensitivity, specificity, positive predictive and negative predictive value of ultrasound parameters for the diagnosis of AD, comparing with the FINAL diagnosis. Lung ultrasound (LUS) showed high sensitivity, good specificity and accuracy in identification of patients with aHF. However, the highest accuracy was obtained by diastolic function parameters. The E/A ratio showed the highest diagnostic performance with an AUC for aHF of 0.93. In patients presenting with AD, E/A ratio is easy to obtain in a fast ultrasound protocol and showed an excellent accuracy for diagnosis of aHF.
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Affiliation(s)
| | - Alfonso Sforza
- Cardiology Department and Cardiology Intensive Care Unit, Santa Maria Delle Grazie, Pozzuoli, Italy
| | - Maria Viviana Carlino
- Cardiology Department and Cardiology Intensive Care Unit, San Giuliano Hospital, Giugliano, Italy
| | | | | | - Dario Bertolone
- Emergency Medicine School & Department of Advanced Biomedical Science, Federico II University Hospital, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Ilaria Fucile
- Emergency Medicine School & Department of Advanced Biomedical Science, Federico II University Hospital, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Nicola De Luca
- Emergency Medicine School & Department of Advanced Biomedical Science, Federico II University Hospital, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Costantino Mancusi
- Emergency Medicine School & Department of Advanced Biomedical Science, Federico II University Hospital, Via Sergio Pansini 5, 80131, Naples, Italy.
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Scheier E. Cardiac POCUS in Pediatric Emergency Medicine: A Narrative Review. J Clin Med 2023; 12:5666. [PMID: 37685733 PMCID: PMC10488602 DOI: 10.3390/jcm12175666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE OF THIS REVIEW The cardiac point of care ultrasound (POCUS) is among the most impactful examinations in the evaluation of an ill child. This paper will review the English-language literature on cardiac POCUS in the pediatric emergency department (PED), the adult emergency literature with relevance to pediatric emergency, and other pediatric cardiac studies outside pediatric emergency with relevance to PED detection of potentially emergent pediatric cardiac pathology. RECENT FINDINGS Pediatric emergency physicians can reliably detect decreased left-sided systolic function and pericardial effusion using POCUS. Case reports show that pediatric emergency physicians have detected right-sided outflow tract obstruction, aortic root dilatation, and congenital cardiac disease using POCUS. Training for pediatric cardiac POCUS competency is feasible, and cardiac POCUS does not increase the burden on cardiology resources to the PED. SUMMARY While cardiac pathology in children is relatively rare, pediatric cardiac POCUS can incorporate a broad curriculum beyond systolic function and the presence of pericardial fluid. Further research should assess pediatric emergency physician performance in the identification of a broader range of cardiac pathology.
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Affiliation(s)
- Eric Scheier
- Pediatric Emergency, Kaplan Medical Center, Rehovot 76100, Israel; ; Tel.: +972-(8)-944-1275; Fax: +972-(8)-944-1276
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel
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3
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King SA, Salerno A, Downing JV, Wynne ZR, Parker JT, Miller TE, Tewelde SZ. POCUS for Diastolic Dysfunction: A Review of the Literature. POCUS JOURNAL 2023; 8:88-92. [PMID: 37152335 PMCID: PMC10155731 DOI: 10.24908/pocus.v8i1.15803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Emergency and critical care physicians frequently encounter patients presenting with dyspnea and normal left ventricular systolic function who may benefit from early diastolic evaluation to determine acute patient management. The current American Society of Echocardiography Guidelines approach to diastolic evaluation is often impractical for point of care ultrasound (POCUS) evaluation, and few studies have evaluated the potential use of a simplified approach. This article reviews the literature on the use of a simplified diastolic evaluation to assist in determining acute patient management.
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Affiliation(s)
- Samantha A King
- Department of Emergency Medicine, University of Maryland School of MedicineBaltimore, MDUSA
| | - Alexis Salerno
- Department of Emergency Medicine, University of Maryland School of MedicineBaltimore, MDUSA
| | - Jessica V Downing
- Program in Trauma/Surgical Critical Care, The R Adams Cowley Shock Trauma Center, University of Maryland Medical CenterBaltimore, MDUSA
| | - Zachary R Wynne
- Department of Emergency Medicine, University of Maryland Medical CenterBaltimore, MDUSA
| | - Jordan T Parker
- Department of Emergency Medicine, University of Maryland Medical CenterBaltimore, MDUSA
| | - Taylor E Miller
- Department of Emergency Medicine, University of Maryland Medical CenterBaltimore, MDUSA
| | - Semhar Z Tewelde
- Department of Emergency Medicine, University of Maryland School of MedicineBaltimore, MDUSA
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Lam SHF, Alade K, Brennan J, Castillo EM, Doniger SJ, Levine MC, Nadolski A, Rabiner JE, Shah V, Sivitz A, Medak AJ. Interpretation Accuracy and Interrater Agreement of Pediatric Skin and Soft Tissue Point-of-Care Ultrasound Images among Residents and Faculty. J Emerg Med 2020; 58:457-463. [PMID: 31843323 DOI: 10.1016/j.jemermed.2019.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) is commonly used to facilitate care in the emergency department. Acquired images are often reviewed by local experts for educational and quality assurance purposes. However, no published study has examined the accuracy and reliability of POCUS image interpretation by multiple reviewers. OBJECTIVES We studied the accuracy and interrater agreement among expert and trainee reviewers of prerecorded pediatric skin and soft tissue (SST) POCUS images. METHODS POCUS faculty and emergency medicine (EM) residents blindly reviewed deidentified pediatric SST POCUS images and indicated whether a drainable fluid collection was present, absent, or indeterminate. This was then compared with the gold standard based on discharge diagnoses and telephone follow-up. Images rated as indeterminate were excluded from the initial analysis. Sensitivity analysis assuming indeterminate answers were inaccurate was subsequently conducted. RESULTS In phase 1, 6 pediatric EM POCUS directors reviewed 168 images. The overall accuracy was 79.7% (range 66.1-86.0%). The mean Cohen's kappa was 0.58 (range 0.24-0.84). Sensitivity analysis yielded an overall accuracy of 71.3% (range 56.5-76.9%) and a Cohen's kappa of 0.43 (range 0.20-0.59). In phase 2, 6 general EM POCUS faculty and 20 EM residents reviewed 120 images. The overall accuracy among residents was 72.2% (range 51.4-84.7%) and among faculty was 83.6% (range 77.9-88.8%). Sensitivity analysis yielded an overall resident accuracy of 63.0% (range 49.5-80.7) and an overall faculty accuracy of 73.9% (range 67.0-79.8%). Fleiss' kappa was 0.322 for residents and 0.461 for faculty. CONCLUSIONS We found moderate accuracy and fair to good interrater agreement among POCUS faculty and EM residents reviewing pediatric SST POCUS images.
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Affiliation(s)
- Samuel H F Lam
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Kiyetta Alade
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine/Texas Children''s Hospital, Houston, Texas
| | - Jesse Brennan
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Edward M Castillo
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Stephanie J Doniger
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, CHOC Children's of Orange, Orange, California
| | - Marla C Levine
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Dell Children's Medical Center of Central Texas, Austin, Texas
| | - Adam Nadolski
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Joni E Rabiner
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University Medical Center/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Virag Shah
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Adam Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Anthony J Medak
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
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Sorensen B, Hunskaar S. Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. Ultrasound J 2019; 11:31. [PMID: 31749019 PMCID: PMC6868077 DOI: 10.1186/s13089-019-0145-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services. METHODS Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound. RESULTS On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies. CONCLUSION Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.
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Affiliation(s)
- Bjarte Sorensen
- Hjelmeland General Practice Surgery, Prestagarden 13, 4130, Hjelmeland, Norway.
| | - Steinar Hunskaar
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Bergen, Norway
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Méndez-Abad P, Zafra-Rodríguez P, Lubián-López S, Benavente-Fernández I. Reproducibility of the assessment of myocardial function through tissue Doppler imaging in very low birth weight infants. Echocardiography 2019; 36:1145-1152. [PMID: 31025771 DOI: 10.1111/echo.14348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 03/30/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES This study aims to analyze the variability between two trained neonatologists when performing consecutive echocardiograms using tissue Doppler imaging (TDI) and conventional methods in very low birth weight infant (VLBWI). METHODS Two serial echocardiograms were performed in 30 VLBWI infants. The echocardiographic parameters analyzed were tricuspid annular plane systolic excursion (TAPSE), A', E', and S' waves, and myocardial performance index acquired by TDI (MPI-TDI) of both ventricles and shortening fraction (SF). The intra-observer and inter-observer agreements and the intra-operator agreement were analyzed using quantitative and qualitative statistical methods. RESULTS The intra-observer agreement was very good, TAPSE, and TDI-derived parameters had an intra-class correlation (ICC) > 0.8. TDI-derived velocities had a coefficient of variation (COV) < 11%, while MPI-TDI had a COV between 20%-28%. The inter-observer agreement was excellent. There was greater variability when analyzing intra-operator agreement, with the least variable parameter being TAPSE. According to PABAK, the variability presented moderately substantial agreement. CONCLUSIONS Tricuspid annular plane systolic excursion is very reproducible between observers and operators. Measurements of TDI wave velocities are more reproducible than MPI-TDI. TDI is sufficiently reproducible in the VLBWI if adequate training is performed, and guidelines are followed to obtain standardized echocardiographic images.
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Affiliation(s)
- Paula Méndez-Abad
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain
| | | | - Simón Lubián-López
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain
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Tamás É, Nylander E. Decision support for assessment of left ventricular diastolic function. Physiol Rep 2018; 6:e13815. [PMID: 30125045 PMCID: PMC6100506 DOI: 10.14814/phy2.13815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 07/07/2018] [Indexed: 11/29/2022] Open
Abstract
Echocardiographic assessment of the left ventricular diastolic function (LVDF), an integrated part of evaluation of left ventricular function is still a delicate task and is performed with substantial inter-rater variability. Therefore, we aimed to create and evaluate a guidelines-based automated decision support. An algorithm was created for a hierarchical analysis of LVDF based on variables as recommended by the latest guidelines. Age-adjusted normal ranges were pooled from previously published studies into an integrated reference table. For proof-of-concept, 20 echocardiographic examinations were analyzed offline by four experienced physicians with more than 10 years of echocardiographic experience. The first assessments were to be performed as they would be in the clinical practice. Six months later, the assessments were repeated based on the 2017 ASE/EACVI guidelines. The overall inter-rater agreement for the first clinical assessments was moderate, while the guidelines-based assessments had only fair inter-rater agreement. Both kinds of manual assessment had poor agreement with the standardized automated assessment algorithm of LVDF. In conclusion, the presented automated decision support for evaluation of diastolic LV function by Doppler echocardiography is mainly based on current guidelines involving multiple parameters in combination. Incorporating age dependency aspects in our program (available for use at https://liu.se/en/research/left-ventricular-diastolic-function-decision-support) enhances the accuracy of the evaluation and reduces variability in evaluation of LVDF. The large inter-rater variation in classification in this study also underscores the usefulness of tools to support a standardized evaluation.
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Affiliation(s)
- Éva Tamás
- Department of Cardiothoracic and Vascular SurgeryDepartment of Medical and Health SciencesLinköping UniversityLinköpingSweden
| | - Eva Nylander
- Department of Clinical PhysiologyDepartment of Medical and Health SciencesLinköping UniversityLinköpingSweden
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8
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Del Rios M, Colla J, Kotini-Shah P, Briller J, Gerber B, Prendergast H. Emergency physician use of tissue Doppler bedside echocardiography in detecting diastolic dysfunction: an exploratory study. Crit Ultrasound J 2018; 10:4. [PMID: 29372430 PMCID: PMC5785451 DOI: 10.1186/s13089-018-0084-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 01/09/2018] [Indexed: 01/20/2023] Open
Abstract
Introduction This study evaluates the agreement between emergency physician (EP) assessment of diastolic dysfunction (DD) by a simplified approach using average peak mitral excursion velocity (eʹA) and an independent cardiologist’s diagnosis of DD by estimating left atrial (LA) pressure using American Society of Echocardiography (ASE) guidelines. Methods This was a secondary analysis of 48 limited bedside echocardiograms (LBE) performed as a part of a research study of patients presenting to the Emergency Department (ED) with elevated blood pressure but without decompensated heart failure. EPs diagnosed DD based on eʹA < 9 cm/s alone. A blinded board-certified cardiologist reviewed LBEs to estimate LA filling pressures following ASE guidelines. An unweighted kappa measure was calculated to determine agreement between EP and cardiologist. Results Six LBEs were deemed indeterminate by the cardiologist and excluded from the analysis. Agreement was reached in 41 out of 48 cases (85.4%). The unweighted kappa coefficient was 0.74 (95% CI 0.57–0.92). EPs identified 18 out of 20 LBEs diagnosed with diastolic dysfunction by the cardiologist. Conclusion There is a good agreement between (eʹA) by EP and cardiologist interpretation of LBEs. Future studies should investigate this simplified approach as a one-step method of screening for LV diastolic dysfunction in the ED.
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Affiliation(s)
- Marina Del Rios
- Department of Emergency Medicine, University of Illinois at Chicago, Chicago, Illinois, USA.
| | - Joseph Colla
- Department of Emergency Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Pavitra Kotini-Shah
- Department of Emergency Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Joan Briller
- Department of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ben Gerber
- Department of Internal Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Heather Prendergast
- Department of Emergency Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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Abbott TEF, Gooneratne M, McNeill J, Lee A, Levett DZH, Grocott MPW, Swart M, MacDonald N. Inter-observer reliability of preoperative cardiopulmonary exercise test interpretation: a cross-sectional study. Br J Anaesth 2017; 120:475-483. [PMID: 29452804 DOI: 10.1016/j.bja.2017.11.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/13/2017] [Accepted: 11/15/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Despite the increasing importance of cardiopulmonary exercise testing (CPET) for preoperative risk assessment, the reliability of CPET interpretation is unclear. We aimed to assess inter-observer reliability of preoperative CPET. METHODS We conducted a prospective, multi-centre, observational study of preoperative CPET interpretation. Participants were professionals with previous experience or training in CPET, assessed by a standardized questionnaire. Each participant interpreted 100 tests using standardized software. The CPET variables of interest were oxygen consumption at the anaerobic threshold (AT) and peak oxygen consumption (VO2 peak). Inter-observer reliability was measured using intra-class correlation coefficient (ICC) with a random effects model. Results are presented as ICC with 95% confidence interval, where ICC of 1 represents perfect agreement and ICC of 0 represents no agreement. RESULTS Participants included 8/28 (28.6%) clinical physiologists, 10 (35.7%) junior doctors, and 10 (35.7%) consultant doctors. The median previous experience was 140 (inter-quartile range 55-700) CPETs. After excluding the first 10 tests (acclimatization) for each participant and missing data, the primary analysis of AT and VO2 peak included 2125 and 2414 tests, respectively. Inter-observer agreement for numerical values of AT [ICC 0.83 (0.75-0.90)] and VO2 peak [ICC 0.88 (0.84-0.92)] was good. In a post hoc analysis, inter-observer agreement for identification of the presence of a reportable AT was excellent [ICC 0.93 (0.91-0.95)] and a reportable VO2 peak was moderate [0.73 (0.64-0.80)]. CONCLUSIONS Inter-observer reliability of interpretation of numerical values of two commonly used CPET variables was good (>80%). However, inter-observer agreement regarding the presence of a reportable value was less consistent.
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Affiliation(s)
- T E F Abbott
- William Harvey Research Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK.
| | | | | | - A Lee
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - D Z H Levett
- Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton-University of Southampton, Southampton, UK
| | - M P W Grocott
- Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton-University of Southampton, Southampton, UK
| | - M Swart
- South Devon Healthcare NHS Trust, Torbay, UK
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