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Chou AK, Chiu CC, Zhu GC, Wang JJ, Chen YW, Hung CH. Naphazoline and oxymetazoline are superior to epinephrine in enhancing the cutaneous analgesia of lidocaine in rats. Fundam Clin Pharmacol 2023; 37:296-304. [PMID: 36394965 DOI: 10.1111/fcp.12853] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 11/06/2022] [Accepted: 11/16/2022] [Indexed: 11/18/2022]
Abstract
This study observed the cutaneous analgesic effect of adrenergic agonists when combined with lidocaine. We aimed at the usefulness of four adrenergic agonists and epinephrine as analgesics or as tools to prolong the effect of local anesthetics using a model of cutaneous trunci muscle reflex (pinprick pain) in rats. We showed that subcutaneous four adrenergic agonists and epinephrine, as well as the local anesthetic bupivacaine and lidocaine, developed a concentration-dependent cutaneous analgesia. The rank order of the efficacy of different compounds (ED50 ; median effective dose) was epinephrine [0.013 (0.012-0.014) μmol] > oxymetazoline [0.25 (0.22-0.28) μmol] > naphazoline [0.42 (0.34-0.53) μmol] = bupivacaine [0.43 (0.37-0.50) μmol] > xylometazoline [1.34 (1.25-1.45) μmol] > lidocaine [5.86 (5.11-6.72) μmol] > tetrahydrozoline [6.76 (6.21-7.36) μmol]. The duration of full recovery caused by tetrahydrozoline, oxymetazoline, or xylometazoline was greater (P < 0.01) than that induced via epinephrine, bupivacaine, lidocaine, or naphazoline at equianesthetic doses (ED25 , ED50 , and ED75 ). Co-administration of lidocaine (ED50 ) with four adrenergic agonists or epinephrine enhanced the cutaneous analgesic effect. We observed that four adrenergic agonists and epinephrine induce analgesia by themselves, and such an effect has a longer duration than local anesthetics. Co-administration of lidocaine with the adrenergic agonist enhances the analgesic effect, and the cutaneous analgesic effect of lidocaine plus naphazoline (or oxymetazoline) is greater than that of lidocaine plus epinephrine.
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Affiliation(s)
- An-Kuo Chou
- Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, E-Da Cancer Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Guan-Cheng Zhu
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Anesthesiology, Tri-Service General Hospital & National Defense Medical Center, Taipei, Taiwan.,Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
| | - Yu-Wen Chen
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan.,Department of Physical Therapy, College of Health Care, China Medical University, Taichung, Taiwan
| | - Ching-Hsia Hung
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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2
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Zavanelli N, Lee SH, Guess M, Yeo WH. Soft wireless sternal patch to detect systemic vasoconstriction using photoplethysmography. iScience 2023; 26:106184. [PMID: 36879814 PMCID: PMC9985026 DOI: 10.1016/j.isci.2023.106184] [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: 11/17/2022] [Revised: 01/16/2023] [Accepted: 02/07/2023] [Indexed: 02/16/2023] Open
Abstract
Vasoconstriction is a crucial physiological process that serves as the body's primary blood pressure regulation mechanism and a key marker of numerous harmful health conditions. The ability to detect vasoconstriction in real time would be crucial for detecting blood pressure, identifying sympathetic arousals, characterizing patient wellbeing, detecting sickle cell anemia attacks early, and identifying complications caused by hypertension medications. However, vasoconstriction manifests weakly in traditional photoplethysmogram (PPG) measurement locations, like the finger, toe, and ear. Here, we report a wireless, fully integrated, soft sternal patch to capture PPG signals from the sternum, an anatomical region that exhibits a robust vasoconstrictive response. With healthy controls, the device is highly capable of detecting vasoconstriction induced endogenously and exogenously. Furthermore, in overnight trials with patients with sleep apnea, the device shows a high agreement (r2 = 0.74) in vasoconstriction detection with a commercial system, demonstrating its potential use in portable, continuous, long-term vasoconstriction monitoring.
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Affiliation(s)
- Nathan Zavanelli
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA 30024, USA.,IEN Center for Human-Centric Interfaces and Engineering at the Institute for Electronics and Nanotechnology, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Sung Hoon Lee
- IEN Center for Human-Centric Interfaces and Engineering at the Institute for Electronics and Nanotechnology, Georgia Institute of Technology, Atlanta, GA 30332, USA.,School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Matthew Guess
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA 30024, USA.,IEN Center for Human-Centric Interfaces and Engineering at the Institute for Electronics and Nanotechnology, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Woon-Hong Yeo
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA 30024, USA.,IEN Center for Human-Centric Interfaces and Engineering at the Institute for Electronics and Nanotechnology, Georgia Institute of Technology, Atlanta, GA 30332, USA.,Wallace H. Coulter Department of Biomedical Engineering, Georgia Tech and Emory University School of Medicine, Atlanta, GA 30332, USA.,Parker H. Petit Institute for Bioengineering and Biosciences, Neural Engineering Center, Institute for Materials, Institute for Robotics and Intelligent Machines, Georgia Institute of Technology, Atlanta, GA 30332, USA
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3
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Formulation considerations for improving intranasal delivery of CNS acting therapeutics. Ther Deliv 2022; 13:371-381. [DOI: 10.4155/tde-2022-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
One of the principal impediments for the treatment of neurological conditions is the lack of ability of most of the medicinal agents to evade the blood–brain barrier. Among all the novel approaches to bypass the blood–brain barrier, nose to brain transport is the most patient compliant, non-invasive and effective approach. It directly transports drugs to the CNS via the trigeminal and olfactory nerves present in the nasal cavity. This review article focuses on anatomy and physiology of nasal cavity, potential of intranasal drug delivery, mechanisms of drug transport to brain, its advantages and limitations, novel intranasal formulations, marketed products, factors affecting nose to brain transport, formulation consideration of intranasal products and the future perspectives of CNS targeting via intranasal drug administration.
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Conceptual Model for Using Imidazoline Derivative Solutions in Pulpal Management. J Clin Med 2021; 10:jcm10061212. [PMID: 33803990 PMCID: PMC7998280 DOI: 10.3390/jcm10061212] [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: 02/02/2021] [Revised: 03/02/2021] [Accepted: 03/11/2021] [Indexed: 11/17/2022] Open
Abstract
Alpha-adrenergic agonists, such as the Imidazoline derivatives (ImDs) of oxymetazoline and xylometazoline, are highly effective hemostatic agents. ImDs have not been widely used in dentistry but their use in medicine, specifically in ophthalmology and otolaryngology, warrants consideration for pulpal hemostasis. This review presents dental healthcare professionals with an overview of ImDs in medicine. ImD solutions have the potential to be more effective and biocompatible than existing topical hemostatic compounds in pulpal management. Through a comprehensive analysis of the pharmacology of ImDs and the microphysiology of hemostasis regulation in oral tissues, a conceptual model of pulpal management by ImD solutions is presented.
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5
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Affiliation(s)
- Hadi Seikaly
- From the Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Canada
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6
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Sryma PB, Mittal S, Tiwari P, Mohan A, Hadda V, Guleria R, Madan K. Topical nasal xylometazoline for flexible bronchoscopy (VAIN): A randomized, double-blind, placebo-controlled trial. Respir Investig 2021; 59:350-355. [PMID: 33518471 DOI: 10.1016/j.resinv.2020.12.004] [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: 06/23/2020] [Revised: 10/27/2020] [Accepted: 12/10/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The role of topical nasal vasoconstrictor administration during flexible bronchoscopy is unclear. METHODS Consecutive subjects undergoing flexible bronchoscopy were randomized to receive either topical xylometazoline (0.1%) or placebo (saline nasal spray, 0.74% w/v isotonic solution) before bronchoscopy. Background topical anesthesia included 2% nasal lignocaine gel, pharyngeal spray of 10% lignocaine, and 1% lignocaine solution for spray-as-you-go administration. The primary outcome was the operator rated ease of nasal negotiation of the bronchoscope on the visual analog scale (Negotiation VAS). Secondary objectives included assistant rated facial pain scale score, patient-rated nasal pain score (Pain VAS), time to reach the vocal cords after bronchoscope insertion, operator rated nasal mucosal trauma score (Trauma VAS), hemodynamic changes, and complications between the groups. RESULTS In all, 148 subjects were recruited and randomized to the placebo (73) and xylometazoline groups (75). Operator rated ease of nasal bronchoscope negotiation (Negotiation VAS) was similar in both the groups [Median (IQR), 1 (1-2) in both groups, p = 0.79]. There were no differences in the other outcomes including assistant rated score of facial pain [(Median (IQR), 2 (2-4) placebo and 2 (2-4) xylometazoline, p = 0.36], Pain VAS [Median (IQR), placebo 2 (1-2) and xylometazoline 2 (1-3), p = 0.28], Trauma VAS, [Median (IQR), placebo 1 (0-2) and xylometazoline 1 (0-1), p = 0.28], hemodynamic changes, or complications between the two groups. CONCLUSION The findings of this study do not support the administration of topical nasal xylometazoline in flexible bronchoscopy. TRIAL REGISTRY Trial registered on Clinicaltrials.gov, www.clinicaltrials.govNCT03424889, on January 02, 2018.
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Affiliation(s)
- P B Sryma
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India.
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7
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Simplified management of epistaxis. J Am Assoc Nurse Pract 2021; 33:1024-1029. [PMID: 33463979 DOI: 10.1097/jxx.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 09/02/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Primary care, urgent care, and emergency department providers periodically treat epistaxis, either as recurrent nosebleed or an acute persistent episode. Silver nitrate application to the decongested and anesthetized nasal mucosa addresses the former in most cases. The plethora of commercial nasal packing devices testifies to the discomfort, technical difficulty, and frustration associated with traditional gauze-packing methods. Inflatable anterior nasal balloon packs reliably control most nosebleeds. Addition of a Foley catheter nasopharyngeal balloon pack manages most posterior epistaxis. Cautery and the two packing techniques mentioned above should treat most cases not requiring otolaryngology consultation or interventional radiology. Appropriate anesthetic and analgesics lessen the unpleasantness for both the patient and the provider. Topical moisturizing facilitates mucosal healing. Oxymetazoline 0.05% nasal spray provides the patient means to address rebleeding after discharge from treatment.
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Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, Alikhaani JD, Benoit MM, Bercovitz RS, Brown MD, Chernobilsky B, Feldstein DA, Hackell JM, Holbrook EH, Holdsworth SM, Lin KW, Lind MM, Poetker DM, Riley CA, Schneider JS, Seidman MD, Vadlamudi V, Valdez TA, Nnacheta LC, Monjur TM. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg 2020; 162:S1-S38. [PMID: 31910111 DOI: 10.1177/0194599819890327] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds. PURPOSE The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.
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Affiliation(s)
- David E Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Spencer C Payne
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stacey L Ishman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | | | | | - Rachel S Bercovitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | | | - Jesse M Hackell
- Pomona Pediatrics, Boston Children's Health Physicians, Pomona, New York, USA
| | | | | | | | - Meredith Merz Lind
- Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
| | | | | | - John S Schneider
- Washington University School of Medicine, St Louis, Missouri, USA
| | - Michael D Seidman
- AdventHealth Medical Group, Celebration, Florida, USA.,University of Central Florida, Orlando, Florida, USA.,University of South Florida, Tampa, Florida, USA
| | | | | | - Lorraine C Nnacheta
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
| | - Taskin M Monjur
- American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Abstract
Palliative wound care is a philosophy of wound management that prioritizes comfort over healing and attends to the emotional distress these wounds can cause. Intervention strategies focus on management of symptoms such as pain, odor, bleeding, and exudate. Historic treatments such as honey, chlorine, and vinegar have gained renewed interest, and although well suited to the palliative setting, there is an increasing amount of research exploring their efficacy in other contexts. The lived experience of patients and caregivers facing these wounds is often stressful and isolating, and any treatment plan must address these issues along with the physical aspects of care.
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Chandrakantan A, Mohammad S, Adler AC. Anesthetic management of acute nasal epistaxis occurring during general anesthesia. Paediatr Anaesth 2019; 29:872-874. [PMID: 31166054 DOI: 10.1111/pan.13678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 06/01/2019] [Indexed: 11/27/2022]
Abstract
Spontaneous epistaxis under general anesthesia is a rare untoward event. Typically, mild epistaxis occurs from a nasal airway manipulation and usually resolves spontaneously or with external pressure to the affected nares for a short period of time. In case of epistaxis that is difficult to control with pressure or oxymetazoline, thorough evaluation should be considered. We present a case of a 12-year-old experiencing spontaneous nasal bleeding upon emergence difficult to control with noninvasive methods and required intervention by otolaryngology.
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Affiliation(s)
- Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
| | - Shazia Mohammad
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
| | - Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
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