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Slidell MB, McAteer J, Miniati D, Sømme S, Wakeman D, Rialon K, Lucas D, Beres A, Chang H, Englum B, Kawaguchi A, Gonzalez K, Speck E, Villalona G, Kulaylat A, Rentea R, Yousef Y, Darderian S, Acker S, St Peter S, Kelley-Quon L, Baird R, Baerg J. Management of Gastroschisis: Timing of Delivery, Antibiotic Usage, and Closure Considerations (A Systematic Review From the American Pediatric Surgical Association Outcomes & Evidence Based Practice Committee). J Pediatr Surg 2024; 59:1408-1417. [PMID: 38796391 DOI: 10.1016/j.jpedsurg.2024.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 03/08/2024] [Accepted: 03/17/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND No consensus exists for the initial management of infants with gastroschisis. METHODS The American Pediatric Surgical Association (APSA) Outcomes and Evidenced-based Practice Committee (OEBPC) developed three a priori questions about gastroschisis for a qualitative systematic review. We reviewed English-language publications between January 1, 1970, and December 31, 2019. This project describes the findings of a systematic review of the three questions regarding: 1) optimal delivery timing, 2) antibiotic use, and 3) closure considerations. RESULTS 1339 articles were screened for eligibility; 92 manuscripts were selected and reviewed. The included studies had a Level of Evidence that ranged from 2 to 4 and recommendation Grades B-D. Twenty-eight addressed optimal timing of delivery, 5 pertained to antibiotic use, and 59 discussed closure considerations (Figure 1). Delivery after 37 weeks post-conceptual age is considered optimal. Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until definitive closure. Studies support primary fascial repair, without staged silo reduction, when abdominal domain and hemodynamics permit. A sutureless repair is safe, effective, and does not delay feeding or extend length of stay. Sedation and intubation are not routinely required for a sutureless closure. CONCLUSIONS Despite the large number of studies addressing the above-mentioned facets of gastroschisis management, the data quality is poor. A wide variation in gastroschisis management was documented, indicating a need for high quality RCTs to provide an evidence-based approach when caring for these infants. TYPE OF STUDY Qualitative systematic review of Level 1-4 studies.
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Affiliation(s)
- Mark B Slidell
- Division of Pediatric Surgery, Johns Hopkins Children's Center, 1800 Orleans St, Baltimore, MD 21287, USA.
| | - Jarod McAteer
- Providence Hospital, 101 West 8th Avenue, Spokane, WA 99204, USA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Northern California, 1600 Eureka Road, Roseville, CA 95661, USA
| | - Stig Sømme
- Division of Pediatric Surgery, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Derek Wakeman
- University of Rochester Medical Center, School of Medicine and Dentistry, 601 Elmwood Ave, Box Surg, Rochester, NY 14642, USA
| | - Kristy Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, USA
| | - Don Lucas
- Division of Pediatric Surgery, Department of General Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA
| | - Alana Beres
- Division of Pediatric Surgery, St. Christopher's Hospital for Children, 160 E Erie Ave, Philadelphia, PA 19134, USA
| | - Henry Chang
- Johns Hopkins All Children's Hospital, 501 6th Avenue South, St. Petersburg, FL 33701, USA
| | - Brian Englum
- University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, USA
| | - Akemi Kawaguchi
- Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA
| | | | - Elizabeth Speck
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E Hospital Dr, Ann Arbor, MI 48109, USA
| | - Gustavo Villalona
- Division of Pediatric Surgery, Nemours Children's Health, 807 Children's Way, Jacksonville, FL 32207, USA
| | - Afif Kulaylat
- Division of Pediatric Surgery, Penn State Hershey Children's Hospital, 200 Campus Dr Ste 400, Hershey, PA 17033, USA
| | - Rebecca Rentea
- Pediatric Surgery Division, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, 1001 Decarie Boulevard, Montreal, Quebec, Canada H4A 3J1
| | - Sarkis Darderian
- Pediatric Surgery Division, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shannon Acker
- Pediatric Surgery Division, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shawn St Peter
- Pediatric Surgery Division, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Lorraine Kelley-Quon
- Pediatric Surgery Division, Children's Hospital, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Robert Baird
- Division of Pediatric General Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, 11th Floor, Vancouver, British Columbia V5Z 1M9, Canada
| | - Joanne Baerg
- Division of Pediatric Surgery, Presbyterian Health System, 201 Cedar St SE Ste 4660, Albuquerque, NM 87106, USA
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Assessment of Antimicrobial Potential of Plagiochasma rupestre Coupled with Healing Clay Bentonite and AGNPS. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4264466. [PMID: 35880032 PMCID: PMC9308554 DOI: 10.1155/2022/4264466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/19/2022] [Accepted: 05/21/2022] [Indexed: 11/17/2022]
Abstract
The impact of individual component, i.e., plant extract (Plagiochasma rupestre), biosynthesized silver nanoparticles (AgNPs), and healing clay (bentonite) as antimicrobial agent is reported but their combined effect as a ternary system is a new approach. This study is aimed at investigating the impact of the proposed ternary system against selected human pathogens. AgNPs were synthesized by using Plagiochasma rupestre extract (aqueous) as reducing agent and neutral polymer (PVP) as stabilizer. The morphology, size, and structural properties of synthesized AgNPs were determined with XRD and SEM analysis which showed spherical monomodal particles with an average particle size of 25.5 nm. The antibacterial and antifungal activities of the individual and nanoternary system were investigated. The phytochemical screening of plant extract showed the presence of alkaloids, flavonoids, phenol, and glycosides in methanol extract as compare to aqueous and acetone extract. The antimicrobial activities of crude extracts of Plagiochasma rupestre with AgNPs and bentonite clay were studied as an appropriate candidate for treatment of microbial infections, especially bacterial and fungal diseases. The antioxidant activity of Plagiochasma rupestre aqueous extract and nanoparticles was assessed by (DPPH) free radical, and absorbance was checked at 517 nm. Crude extract has inhibitory effect towards bacteria and fungi, and bentonite clay also showed some degree of antimicrobial resistance. Strategy can be efficiently applied for future engineering and medical. The nanoternary systems showed 3 and 3.5 times higher antibacterial and antifungal activity, respectively, in comparison to Plagiochasma rupestre and bentonite clay, individually.
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Riddle S, Haberman B, Miquel-Verges F, Somme S, Sullivan K, Rajgarhia A, Zaniletti I, Jacobson E. Gastroschisis with intestinal atresia leads to longer hospitalization and poor feeding outcomes. J Perinatol 2022; 42:254-259. [PMID: 34155327 DOI: 10.1038/s41372-021-01131-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/21/2021] [Accepted: 06/04/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Compare in-hospital outcomes in gastroschisis with intestinal atresia versus simple gastroschisis (GS) using a national database. STUDY DESIGN The Children's Hospitals Neonatal Database identified infants with gastroschisis from 2010 to 2016. RESULTS 2078 patients with gastroschisis were included: 183 (8.8%) with co-existing intestinal atresia, 1713 (82.4%) with simple gastroschisis, the remainder with complex gastroschisis without atresia. Length of hospitalization was longer for those with atresia, and yielded higher rates of mortality, medical NEC, and intestinal perforation. They began enteral feedings later, were less likely to initiate feeds orally, and reached full feedings later. They were less likely to be receiving any maternal breast milk or breastfeeding at discharge and more likely than simple gastroschisis to be discharged with a feeding tube. CONCLUSION A large multicenter cohort showed gastroschisis with atresia results in worse outcomes and complications, including necrotizing enterocolitis, feeding delays, and enteral feeding tube dependence.
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Affiliation(s)
- Stefanie Riddle
- Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Beth Haberman
- Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Franscesca Miquel-Verges
- Arkansas Children's Hospital and Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Stig Somme
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Kevin Sullivan
- Nemours/AI Dupont Hospital for Children, Wilmington, DE, USA.,Department of Pediatrics of Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Ayan Rajgarhia
- Children's Mercy Hospital and University of Missouri - Kansas City School of Medicine, Kansas, MO, USA
| | | | - Elizabeth Jacobson
- Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
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Cuna A, Lagatta JM, Savani RC, Vyas-Read S, Engle WA, Rose RS, DiGeronimo R, Logan JW, Mikhael M, Natarajan G, Truog WE, Kielt M, Murthy K, Zaniletti I, Lewis TR. Association of time of first corticosteroid treatment with bronchopulmonary dysplasia in preterm infants. Pediatr Pulmonol 2021; 56:3283-3292. [PMID: 34379886 PMCID: PMC8453128 DOI: 10.1002/ppul.25610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/13/2021] [Accepted: 07/31/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the association between the time of first systemic corticosteroid initiation and bronchopulmonary dysplasia (BPD) in preterm infants. STUDY DESIGN A multi-center retrospective cohort study from January 2010 to December 2016 using the Children's Hospitals Neonatal Database and Pediatric Health Information System database was conducted. The study population included preterm infants <32 weeks' gestation treated with systemic corticosteroids after 7 days of age and before 34 weeks' postmenstrual age. Stepwise multivariable logistic regression was used to assess the association between timing of corticosteroid initiation and the development of Grade 2 or 3 BPD as defined by the 2019 Neonatal Research Network criteria. RESULTS We identified 598 corticosteroid-treated infants (median gestational age 25 weeks, median birth weight 760 g). Of these, 47% (280 of 598) were first treated at 8-21 days, 25% (148 of 598) were first treated at 22-35 days, 14% (86 of 598) were first treated at 36-49 days, and 14% (84 of 598) were first treated at >50 days. Infants first treated at 36-49 days (aOR 2.0, 95% CI 1.1-3.7) and >50 days (aOR 1.9, 95% CI 1.04-3.3) had higher independent odds of developing Grade 2 or 3 BPD when compared to infants treated at 8-21 days after adjusting for birth characteristics, admission characteristics, center, and co-morbidities. CONCLUSIONS Among preterm infants treated with systemic corticosteroids in routine clinical practice, later initiation of treatment was associated with a higher likelihood to develop Grade 2 or 3 BPD when compared to earlier treatment.
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Affiliation(s)
- Alain Cuna
- Children's Mercy Kansas City, University of Missouri, Kansas, Missouri, USA
| | - Joanne M Lagatta
- Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rashmin C Savani
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shilpa Vyas-Read
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - William A Engle
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rebecca S Rose
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert DiGeronimo
- Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - J Wells Logan
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Michel Mikhael
- Neonatal-Perinatal Medicine Division, Children's Hospital of Orange County, Orange, California, USA
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Detroit, Missouri, USA
| | - William E Truog
- Children's Mercy Kansas City, University of Missouri, Kansas, Missouri, USA
| | - Matthew Kielt
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Karna Murthy
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Tamorah R Lewis
- Children's Mercy Kansas City, University of Missouri, Kansas, Missouri, USA
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Failure of primary closure predicts prolonged length of stay in gastroschisis patients. Pediatr Surg Int 2021; 37:77-83. [PMID: 33151349 DOI: 10.1007/s00383-020-04772-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Current literature regarding outcomes of gastroschisis closure methods do not highlight differences in patients who successfully undergo primary closure with those who fail and require silo placement. We hypothesize that failure of primary closure has significant effects on clinical outcomes such as length of stay and time to enteral feeding. METHODS We conducted a retrospective review between 2009 and 2018 of gastroschisis patients at a tertiary pediatric referral hospital. We compared patients successfully undergoing primary closure to patients who failed an initial primary closure attempt. Bivariate and multivariate linear regression models were used to assess the association of closure method on clinical outcomes. RESULTS Sixty-eight neonates were included for analysis, with 44 patients who underwent primary closure and 24 who failed primary closure. On multivariate regression analysis, primary closure patients had shorter estimated time to starting and to full enteral feeds and decreased LOS as compared to those who failed primary closure. Two patients (4.44%) had complications related to primary closure. CONCLUSION Patients able to undergo primary closure for gastroschisis were more likely to have a shorter length of stay, shorter time to enteral feeds, and use much fewer medical resources. Initial primary closure is a safe method for most patients.
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Gilliam EA, Vu K, Rao P, Krishnaswami S, Hamilton N, Azarow K, Gingalewski C, Jafri M, Zigman A, Butler M, Fialkowski EA. Minimizing Variance in Gastroschisis Management Leads to Earlier Full Feeds in Delayed Closure. J Surg Res 2021; 257:537-544. [DOI: 10.1016/j.jss.2020.07.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/20/2020] [Accepted: 07/11/2020] [Indexed: 12/16/2022]
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Shalaby A, Obeida A, Khairy D, Bahaaeldin K. Assessment of gastroschisis risk factors in Egypt. J Pediatr Surg 2020; 55:292-295. [PMID: 31759649 DOI: 10.1016/j.jpedsurg.2019.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 10/26/2019] [Indexed: 01/15/2023]
Abstract
AIM Mortality in infants born with gastroschisis (GS) in low-to-middle-income countries (LMICs) is high. This study aimed to assess factors which might affect outcome in Egypt in order to improve survival. METHODS A prospective study over a 15-month duration was completed. Variables assessed covered patient, maternal, antenatal, treatment, and complications. The Gastroschisis Prognostic Score (GPS) was used to predict outcome. A validated questionnaire was used to assess socioeconomic status. The main outcome was mortality. RESULTS Twenty-four cases were studied. Median gestational age was 37 (26-40) weeks, and 9 (38%) were preterm. Mortality occurred in 15 (62%) infants. Median transfer time was 8 (1.5-35) hours, and 64% survived if transferred before 8 h. Median maternal age was 20 (16-27) years. All families were of a low or very-low socioeconomic level. Only 25% had antenatal scans. Most cases were simple GS, and only 3 (12.5%) were complex GS. Median length of stay was 14 (1-52) days, TPN duration was 12 (0-49) days, and days to full feeds was 5 (3-11) days. The GPS score ranged from 0 to 6 in the studied cases and negatively correlated with outcome (rS = -0.98; p = 0.03). CONCLUSION The mortality of GS in Egypt is very high, mainly due to sepsis and prematurity. Young maternal age and poor socioeconomic status are linked to GS. The GPS is a good indicator of morbidity and mortality in a LMIC setting. Survival improved with better resuscitation and strict management protocols. More effort is needed to improve antenatal detection, and transfer time should be ideally below 8 h. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Aly Shalaby
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital.
| | - Alaa Obeida
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital
| | - Dalia Khairy
- Department of Pediatrics, Cairo University Specialized Pediatric Hospital
| | - Khaled Bahaaeldin
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital
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Association of Neonatologist Continuity of Care and Short-Term Patient Outcomes. J Pediatr 2019; 212:131-136.e1. [PMID: 31201026 DOI: 10.1016/j.jpeds.2019.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/10/2019] [Accepted: 05/10/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To describe neonatologist continuity of care and estimate the association between these transitions and selected patient outcomes. STUDY DESIGN We linked Children's Hospitals Neonatal Database records with masked neonatologist daily schedules at 4 centers, which use 2- and 3-week and 1-month "on service" blocks to provide care. After describing the neonatologist transitions, we estimated associations between these transitions and selected short-term patient outcomes using multivariable Poisson, logistic, and linear regression analyses, independent of length of stay (LOS) and case-mix. We also completed analyses after stratifying the cohort by LOS, birthweight, age at admission categories, and selected diagnoses. RESULTS Stratified by LOS, patient transitions varied between centers in both unadjusted (P < .001) and multivariable analyses (adjusted incidence rate ratio; 95% CI for center B = 3.98 (3.81-4.15), center C = 4.92 (4.71-5.13), center D = 4.2 (4.0-4.4), P < .001), independent of LOS, gestational age, birthweight, surgical intervention, ventilator duration, and mortality. Only central venous line duration (adjusted incidence rate ratio 1.015, 95% CI 1.01-1.02) was minimally and independently associated with the number of transitions. No differences were observed in ventilator duration, oxygen use at neonatal intensive care unit discharge, bloodstream infections, or urinary tract infections. Surviving infants with meconium aspiration, hypoxic ischemic encephalopathy, cerebral infarction, bronchopulmonary dysplasia, and diaphragmatic hernia demonstrated similar findings. CONCLUSIONS Transitions in neonatologists are frequent in regional neonatal intensive care units but appear unrelated to short-term patient outcomes. Future work to define continuity of care and develop effective strategies that promote longitudinal inpatient management is needed.
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Palatnik A, Loichinger M, Wagner A, Peterson E. The association between gestational age at delivery, closure type and perinatal outcomes in neonates with isolated gastroschisis. J Matern Fetal Neonatal Med 2018; 33:1393-1399. [PMID: 30173575 DOI: 10.1080/14767058.2018.1519538] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: The objective of this study was to examine the association between gestational age at delivery and closure type for neonates with gastroschisis. In addition, we compared perinatal outcomes among the cases of gastroschisis based on the following two factors: gestational age at delivery and abdominal wall closure technique.Methods: This was a retrospective cohort study of all fetuses with isolated gastroschisis that were diagnosed prenatally and delivered between September 2000 and January 2017, in a single tertiary care center. Neonates were compared based on the gestational age at the time of delivery: early preterm (less than 350/7 weeks), late preterm (350/7 - 366/7 weeks), and early term (370/6 - 386/7 weeks), using bivariate and multivariate analyses. The primary outcome was the type of abdominal wall closure: primary surgical closure or delayed closure using spring-loaded silo. Secondary outcomes included length of ventilatory support, length of parenteral nutrition, and length of hospital stay.Results: The analysis included 206 pregnancies complicated by gastroschisis. In univariate analysis, no differences were detected in primary closure rates of gastroschisis among the gestational age at delivery groups (67.4%, at <35 weeks, 70.8% at 350/7-366/7 weeks, 73.7% at 370/6-386/7 weeks, p = .865). However, for every additional 100 grams of neonatal live birth weight there was an associated 9% increased odds of primary closure (OR 1.09, 95% CI 1.14-1.19, p = .04). Delivery in the early preterm period compared to the other two groups, was associated with longer duration of ventilation support and longer dependence on the parenteral nutrition. Neonates who underwent primary closure had shorter ventilation support, shorter time to initiation of enteral feeds and to discontinue parenteral nutrition, and shorter length of stay. In multivariate analyses, controlling for gestational age at delivery and presence of bowel atresia, primary closure continued to be associated with the shorter duration of ventilation (by 5 days), earlier initiation of enteral feeds (by 7 days), shorter hospital stay (by 17 days) and lower odds of wound infection (OR = 0.37, 95% CI 0.15-0.97).Conclusions: Our study did not find an association between gestational age at delivery and the rates of primary closure of the abdominal wall defect; however later gestational age at delivery was associated with shorter duration of ventilatory support and parenteral nutrition dependence. In addition, we found that primary closure of gastroschisis, compared with delayed closure technique, was associated with improved neonatal outcomes, including shorter time to initiate enteral feeds and discontinue parenteral nutrition, shorter hospital stay, and lower risk of surgical wound infection. Therefore, postponing delivery of fetuses with gastroschisis until 37 weeks may be considered. Other factors besides the gestational age at delivery should be explored as predictors of primary closure in neonates with gastroschisis.
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Affiliation(s)
- Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Amy Wagner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Erika Peterson
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA
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Mansfield SA, Ryshen G, Dail J, Gossard M, McClead R, Aldrink JH. Use of quality improvement (QI) methodology to decrease length of stay (LOS) for newborns with uncomplicated gastroschisis. J Pediatr Surg 2018; 53:1578-1583. [PMID: 29291893 DOI: 10.1016/j.jpedsurg.2017.11.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/26/2017] [Accepted: 11/30/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Gastroschisis is a congenital defect of the abdominal wall leading to considerable morbidity and long hospitalizations. The purpose of this study was to use quality improvement methodology to standardize care in the management of gastroschisis that may contribute to length of stay (LOS). METHODS A gastroschisis quality improvement team established a best-practice protocol in order to decrease LOS in infants with uncomplicated gastroschisis. The specific aim was to decrease median LOS from a baseline of 34days. We used statistical process control charts including rational subgroup analysis to monitor LOS. RESULTS From December 2008 to December 2016, 119 patients with uncomplicated gastroschisis were evaluated. Retrospective data were obtained on 25 patients prior to protocol implementation. Ninety-four patients with uncomplicated gastroschisis comprised the prospective process stage. The median LOS for this retrospective cohort was 34days (IQR: 30.5-50.5), while the median LOS for the prospective cohort following implementation of the protocol decreased to 29days (IQR: 23-43). CONCLUSIONS With the use of quality improvement methodology, including standardization of care and a change in surgical approach, the median LOS for newborns with uncomplicated gastroschisis at our institution decreased from 34days to 29days. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Sara A Mansfield
- Department of General Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Gregory Ryshen
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH
| | - James Dail
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH
| | - Mary Gossard
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Richard McClead
- Department of Pediatrics, Division of Neonatology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH.
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Haddock C, Al Maawali AG, Ting J, Bedford J, Afshar K, Skarsgard ED. Impact of Multidisciplinary Standardization of Care for Gastroschisis: Treatment, Outcomes, and Cost. J Pediatr Surg 2018; 53:892-897. [PMID: 29499843 DOI: 10.1016/j.jpedsurg.2018.02.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 02/01/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND/PURPOSE Elimination of unnecessary practice variation through standardization creates opportunities for improved outcomes and cost-effectiveness. A quality improvement (QI) initiative at our institution used evidence and consensus to standardize management of gastroschisis (GS) from birth to discharge. METHODS An interdisciplinary team utilized best practice evidence and expert opinion to standardize GS care. Following stakeholder engagement and education, care standardization was implemented in September 2014. A comparative cohort study was conducted on consecutive patients treated before (n=33) and after (n=24) standardization. Demographic, treatment, and outcome measures were collected from a prospective GS registry. Direct costs were estimated, and protocol compliance was audited. RESULTS BW, GA, and bowel injury severity were comparable between groups. Key practice changes were: closure technique (pre-88% primary fascial, post-83% umbilical cord flap; p<0.001), closure location (pre-97% OR, post-67% NICU; p<0.001), and GA avoidance (pre-0%, post-48%; p<0.001). Median post-closure ventilation days were shorter (pre-4, post-1; p<0.001), and SSI rates trended lower (pre-21%, post-8%; p=0.3) in the post-implementation group with no differences in TPN days or LOS. No significant difference was seen in average per-patient costs: pre-$85,725 ($29,974-221,061), post-$76,329 ($14,205-176,856). CONCLUSION Care standardization for GS enables practice transformation, cost-effective outcome improvement, and supports an organizational culture dedicated to continuous improvement. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Candace Haddock
- Division of Pediatric Surgery, Department of Surgery, British Columbia Children's Hospital, University of British Columbia. Vancouver, BC, Canada
| | - Al Ghalgya Al Maawali
- Division of Pediatric Surgery, Department of Surgery, British Columbia Children's Hospital, University of British Columbia. Vancouver, BC, Canada
| | - Joseph Ting
- Division of Neonatology, Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Julie Bedford
- Department of Quality and Safety, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Kourosh Afshar
- Division of Pediatric Urology, Department of Surgery, British Columbia Children's Hospital; Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, British Columbia Children's Hospital, University of British Columbia. Vancouver, BC, Canada.
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Short-term and family-reported long-term outcomes of simple versus complicated gastroschisis. J Surg Res 2018; 224:79-88. [DOI: 10.1016/j.jss.2017.11.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 10/03/2017] [Accepted: 11/21/2017] [Indexed: 11/18/2022]
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13
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Gonzalez DO, Cooper JN, St Peter SD, Minneci PC, Deans KJ. Variability in outcomes after gastroschisis closure across U.S. children's hospitals. J Pediatr Surg 2018; 53:513-520. [PMID: 28483165 DOI: 10.1016/j.jpedsurg.2017.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/04/2017] [Accepted: 04/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND In patients undergoing gastroschisis closure, the effects of timing of closure and patient and hospital-level characteristics on length of stay (LOS) and time to enteral autonomy are unknown. STUDY DESIGN Using the Pediatric Health Information System, we compared neonates who underwent early (within 1day of birth) versus delayed (>1day after birth) gastroschisis closure from 2005 to 2013. We evaluated the relationship between time to closure and both LOS and days on total parenteral nutrition (TPN). RESULTS Of 4459 neonates with gastroschisis, 43.9% underwent early closure and 56.1% underwent delayed closure. Delayed closure, complicated gastroschisis, government insurance, lower birth weight, older age at closure, and complex chronic conditions were associated with longer LOS and days on TPN (all p<0.05). There was significant inter-hospital variability in both outcomes, after adjusting for patient- and hospital-level characteristics, including hospitals' gastroschisis and neonatal volumes, median age at closure, and percentages of complicated and delayed gastroschisis patients, (p<0.01). CONCLUSION Delayed gastroschisis closure is associated with longer LOS and duration of TPN, even after excluding complicated cases. Furthermore, after controlling for hospital volume, rate of complicated gastroschisis, and timing of closure, the persistent inter-hospital variability suggests that practice variability is partially responsible for these differences. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dani O Gonzalez
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205; Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029.
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205.
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, 64155.
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205.
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205.
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14
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Fullerton BS, Velazco CS, Sparks EA, Morrow KA, Edwards EM, Soll RF, Modi BP, Horbar JD, Jaksic T. Contemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study. J Pediatr 2017; 188:192-197.e6. [PMID: 28712519 DOI: 10.1016/j.jpeds.2017.06.013] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 04/13/2017] [Accepted: 06/06/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To quantify outcomes and analyze factors predictive of morbidity and mortality in infants with gastroschisis. STUDY DESIGN Clinical data regarding neonates with gastroschisis born between 2009 and 2014 were prospectively collected at 175 North American centers. Multivariate regression was used to assess risk factors for mortality and length of stay (LOS). RESULTS Gastroschisis was diagnosed in 4420 neonates with median birth weight 2410 g (IQR 2105-2747). Survival (discharge home or alive in hospital at 1 year) was 97.8% with a 37 day median LOS (IQR 27-59). Sepsis, defined by positive blood or cerebrospinal fluid culture, was the only significant independent predictor of mortality (P = .04). Significant independent determinants of LOS and the percentage of neonates affected were as follows: bowel resection (9.8%, P < .0001), sepsis (8.6%, P < .0001), presence of other congenital anomalies (7.6%, including 5.8% with intestinal atresias, P < .0001), necrotizing enterocolitis (4.5%, P < .0001), and small for gestational age (37.3%, P = .0006). Abdominal surgery in addition to gastroschisis repair occurred in 22.3%, with 6.4% receiving gastrostomy or jejunostomy tubes and 6.3% requiring ostomy creation. At discharge, 57.0% were less than the 10th percentile weight for age. The mode of delivery (52.4% cesarean delivery) was not associated with any differences in outcome. CONCLUSIONS Although neonates with gastroschisis have excellent overall survival they remain at risk for death from sepsis, prolonged hospitalization, multiple abdominal operations, and malnutrition at discharge. Outcomes appear unaffected by the use of cesarean delivery. Further opportunities for quality improvement include sepsis prevention and enhanced nutritional support.
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Affiliation(s)
- Brenna S Fullerton
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
| | - Cristine S Velazco
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Eric A Sparks
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | - Erika M Edwards
- Vermont Oxford Network, Burlington, VT; University of Vermont, Burlington, VT
| | - Roger F Soll
- Vermont Oxford Network, Burlington, VT; University of Vermont, Burlington, VT
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT; University of Vermont, Burlington, VT
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
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15
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Worthington P, Balint J, Bechtold M, Bingham A, Chan LN, Durfee S, Jevenn AK, Malone A, Mascarenhas M, Robinson DT, Holcombe B. When Is Parenteral Nutrition Appropriate? JPEN J Parenter Enteral Nutr 2017; 41:324-377. [PMID: 28333597 DOI: 10.1177/0148607117695251] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.
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Affiliation(s)
| | - Jane Balint
- 2 Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | - Angela Bingham
- 4 University of the Sciences, Philadelphia, Pennsylvania, USA
| | | | - Sharon Durfee
- 6 Central Admixture Pharmacy Services, Inc, Denver, Colorado, USA
| | | | | | - Maria Mascarenhas
- 9 The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel T Robinson
- 10 Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Beverly Holcombe
- 11 American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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Allin BSR, Irvine A, Patni N, Knight M. Variability of outcome reporting in Hirschsprung's Disease and gastroschisis: a systematic review. Sci Rep 2016; 6:38969. [PMID: 27941923 PMCID: PMC5150519 DOI: 10.1038/srep38969] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 11/14/2016] [Indexed: 02/07/2023] Open
Abstract
Heterogeneity in outcome reporting limits identification of gold-standard treatments for Hirschsprung’s Disease(HD) and gastroschisis. This review aimed to identify which outcomes are currently investigated in HD and gastroschisis research so as to counter this heterogeneity through informing development of a core outcome set(COS). Two systematic reviews were conducted. Studies were eligible for inclusion if they compared surgical interventions for primary treatment of HD in review one, and gastroschisis in review two. Studies available only as abstracts were excluded from analysis of reporting transparency. Thirty-five HD studies were eligible for inclusion in the review, and 74 unique outcomes were investigated. The most commonly investigated was faecal incontinence (32 studies, 91%). Seven of the 28 assessed studies (25%) met all criteria for transparent outcome reporting. Thirty gastroschisis studies were eligible for inclusion in the review, and 62 unique outcomes were investigated. The most commonly investigated was length of stay (24 studies, 80%). None of the assessed studies met all criteria for transparent outcome reporting. This review demonstrates that heterogeneity in outcome reporting and a significant risk of reporting bias exist in HD and gastroschisis research. Development of a COS could counter these problems, and the outcome lists developed from this review could be used in that process.
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Affiliation(s)
- Benjamin Saul Raywood Allin
- National Perinatal Epidemiology Unit, Oxford, OX37LF, UK.,Department of Paediatric Surgery, Oxford Children's Hospital, Oxford, OX39DU, UK
| | - Amy Irvine
- University of Oxford Medical School Medical Sciences Divisional Office University of Oxford Level 3, John Radcliffe Hospital Oxford OX3 9DU, UK
| | - Nicholas Patni
- University of Oxford Medical School Medical Sciences Divisional Office University of Oxford Level 3, John Radcliffe Hospital Oxford OX3 9DU, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Oxford, OX37LF, UK
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Lusk LA, Brown EG, Overcash RT, Grogan TR, Keller RL, Kim JH, Poulain FR, Shew SB, Uy C, DeUgarte DA. Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: a report from the University of California Fetal Consortium (UCfC). J Pediatr Surg 2014; 49:1782-6. [PMID: 25487483 PMCID: PMC4261143 DOI: 10.1016/j.jpedsurg.2014.09.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 09/05/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE Gastroschisis is a resource-intensive birth defect without consensus regarding optimal surgical and medical management. We sought to determine best-practice guidelines by examining differences in multi-institutional practices and outcomes. METHODS Site-specific practice patterns were queried, and infant-maternal chart review was retrospectively performed for gastroschisis infants treated at 5 UCfC institutions (2007-2012). The primary outcome was length of stay. Univariate analysis was done to assess variation practices and outcomes by site. Multivariate models were constructed with site as an instrumental variable and with sites grouped by silo practice pattern adjusting for confounding factors. RESULTS Of 191 gastroschisis infants, 164 infants were uncomplicated. Among uncomplicated patients, there were no deaths and only one case of necrotizing enterocolitis. Bivariate analysis revealed significant differences in practices and outcomes by site. Despite wide variations in practice patterns, there were no major differences in outcome among sites or by silo practice, after adjusting for confounding factors. CONCLUSIONS Wide variability exists in institutional practice patterns for infants with gastroschisis, but poor outcomes were not associated with expeditious silo or primary closure, avoidance of routine paralysis, or limited central line and antibiotic durations. Development of clinical pathways incorporating these practices may help standardize care and reduce health care costs.
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Affiliation(s)
- Laura A Lusk
- University of California, San Francisco, Department of Pediatrics -Division of Neonatology
| | - Erin G Brown
- Department of Surgery, Division of Neonatology, University of California, Davis.
| | - Rachael T Overcash
- Department of Reproductive Medicine, Division of Maternal-Fetal Medicine, University of California, San Diego.
| | - Tristan R Grogan
- Department of Medicine, Division of Health Services Research, University of California, Los Angeles.
| | - Roberta L Keller
- Department of Pediatrics, Division of Neonatology, University of California, San Francisco.
| | - Jae H Kim
- Department of Pediatrics, Division of Neonatology, University of California, San Diego.
| | - Francis R Poulain
- Department of Pediatrics, Division of Neonatology, University of California, Davis.
| | - Steve B Shew
- Department of Surgery, University of California, Los Angeles.
| | - Cherry Uy
- Department of Pediatrics, Division of Neonatology, University of California, Irvine.
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