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Chalia M, Singh D, Boyd SG, Hannam S, Hoskote A, Pressler R. Neonatal seizures during extra corporeal membrane oxygenation support. Eur J Pediatr 2024:10.1007/s00431-024-05510-w. [PMID: 38488877 DOI: 10.1007/s00431-024-05510-w] [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: 01/26/2024] [Revised: 02/28/2024] [Accepted: 03/02/2024] [Indexed: 03/17/2024]
Abstract
To evaluate EEG monitoring during neonatal ECMO and to identify any correlations between seizure detection to abnormal neuroimaging. Eight-year, service evaluation of neonates who received at least one continuous EEG (cEEG) whilst on ECMO at Great Ormond Street Hospital. Pearson's chi-square test and multivariate logistic regression analysis were used to assess clinical and EEG variables association with seizures and neuroimaging findings. Fifty-seven neonates were studied; 57 cEEG recordings were reviewed. The incidence of seizures was 33% (19/57); of these 74% (14/19) were electrographic-only. The incidence of status epilepticus was 42%, (8/19 with 6 neonates having electrographic-only status and 2 electro-clinical status. Seizures were detected within an hour of recording in 84%, (16/19). The overall mortality rate was 39% (22/57). Seizure detection was strongly associated with female gender (OR 4.8, 95% CI: 1.1-20.4, p = 0.03), abnormal EEG background activity (OR 2.8, 95% CI: 1.1-7.4, p = 0.03) and abnormal EEG focal features (OR 23.6, 95% CI: 5.4-103.9, p = 0.001). There was a strong association between the presence of seizures and abnormal neuroimaging findings (OR 10.9, 95% CI: 2.8-41.9, p = 0.001). Neonates were highly likely to have abnormal neuroimaging findings in the presence of severely abnormal background EEG (OR 9.5, 95% CI 1.7-52.02, p = 0.01) and focal EEG abnormalities (OR 6.35, 95% CI 1.97-20.5, p = 0.002)Conclusion: The study highlights the importance of cEEG in neonates undergoing ECMO. An association between seizure detection and abnormal neuroimaging findings was described. What is Known: • Patients on ECMO are at a higher risk of seiures. • Continuous EEG monitoring is recommended by the ACNS for high risk and ECMO patients. What is New: • In this cohort, neonates with sezirues were 11 times more likely of having abnromal neuroimaging findings. • Neonates with burst suppressed or suppressed EEG background were 9.5 times more likely to have abnormal neuroimaging findings. What does this study add? • This study reports a 33% incidence of neonatal seizures during ECMO. • Neonates with seizures were 11 times more likely to have an abnormal brain scan. • The study captures the real-time approach of EEG monitoring. • Recommended cEEG monitoring should last at least 24 h for ECMO patients. • This is the first study to assess this in neonates only.
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Affiliation(s)
- Maria Chalia
- Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
| | - Davinder Singh
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK
| | - Stewart G Boyd
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
| | - Simon Hannam
- Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK
| | - Ronit Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
- Clinical Neuroscience, University College London, UCL, Great Ormond Street Institute of Child Health, London, UK
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Chahine A, Chenouard A, Joram N, Berthomieu L, Du Pont-Thibodeau G, Leclere B, Liet JM, Maminirina P, Leclair-Visonneau L, Breinig S, Bourgoin P. Continuous Amplitude-Integrated Electroencephalography During Neonatal and Pediatric Extracorporeal Membrane Oxygenation. J Clin Neurophysiol 2023; 40:317-324. [PMID: 34387276 DOI: 10.1097/wnp.0000000000000890] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Early prognostication of neurologic outcome in neonates and children supported with extra-corporeal membrane oxygenation (ECMO) is challenging. Amplitude-integrated EEG (aEEG) offers the advantages of continuous monitoring and 24-hours availability at the bedside for intensive care unit providers. The objective of this study was to describe the early electrophysiological background patterns of neonates and children undergoing ECMO and their association with neurologic outcomes. METHODS This was a retrospective review of neonates and children undergoing ECMO and monitored with aEEG. Amplitude-integrated EEG was summarized as an aEEG background score determined within the first 24 hours of ECMO and divided in 3-hour periods. Screening for electrical seizures was performed throughout the full ECMO duration. Neurologic outcome was defined by the Pediatric Cerebral Performance Category score at hospital discharge. RESULTS Seventy-three patients (median age 79 days [8-660], median weight 4.78 kg [3.24-10.02]) were included in the analysis. Thirty-two patients had a favorable neurologic outcome and 41 had an unfavorable neurologic outcome group at hospital discharge. A 24-hour aEEG background score >17 was associated with an unfavorable outcome with a sensitivity of 44%, a specificity of 97%, a positive predictive value of 95%, and a negative predictive value of 57%. In multivariate analysis, 24-hour aEEG background score was associated with unfavorable outcome (hazard ratio, 6.1; p = 0.001; 95% confidence interval, 2.31-16.24). The presence of seizures was not associated with neurologic outcome at hospital discharge. CONCLUSIONS Continuous aEEG provides accurate neurologic prognostication in neonates and children supported with ECMO. Early aEEG monitoring may help intensive care unit providers to guide clinical care and family counseling.
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Affiliation(s)
- Adela Chahine
- Pediatric Intensive Care Unit, University Hospital, Toulouse, France
| | - Alexis Chenouard
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Lionel Berthomieu
- Pediatric Intensive Care Unit, University Hospital, Toulouse, France
| | | | - Brice Leclere
- Department of Medical Evaluation and Epidemiology, Nantes University Hospital, Nantes, France
| | - Jean-Michel Liet
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | | | | | - Sophie Breinig
- Pediatric Intensive Care Unit, University Hospital, Toulouse, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit and Pediatric Cardiac Anesthesia, University Hospital, Nantes, France
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Sansevere AJ, DiBacco ML, Akhondi-Asl A, LaRovere K, Loddenkemper T, Rivkin MJ, Thiagarajan RR, Pearl PL, Libenson MH, Tasker RC. EEG features of brain injury during extracorporeal membrane oxygenation in children. Neurology 2020; 95:e1372-e1380. [PMID: 32631921 DOI: 10.1212/wnl.0000000000010188] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 03/11/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine EEG features of major pathophysiology in children undergoing extracorporeal membrane oxygenation (ECMO). METHODS This was a single-center, retrospective study of 201 pediatric patients on ECMO, using the first 24 hours of continuous EEG (cEEG) monitoring, collating background activity and electrographic seizures (ES) with imaging, ECMO type, and outcome. RESULTS Severely abnormal cEEG background occurred in 12% (25/201), and was associated with death (sensitivity 0.23, specificity 0.97). ES occurred in 16% (33/201) within 3.2 (0.6-20.3) hours (median [interquartile range]) of cEEG commencement, and higher ES burden was associated with death. ES was always associated with ipsilateral injury (p = 0.006), but occurred in only one-third of cases with abnormal imaging. In 28 patients with isolated hemisphere lesion, type of arterial ECMO cannulation was associated with side of injury: right carotid cannulation was associated with right hemisphere lesions, and ascending aorta cannulation with left hemisphere lesions (odds ratio, 0.29 [95% confidence interval, 0.08-0.98], p = 0.03). CONCLUSIONS After starting ECMO, cEEG background activity has the potential to inform prognosis. Type of arterial (carotid vs aortic) ECMO correlates with side of focal cerebral injury, which in ≈33% is associated with presence of ES. We hypothesize that the differential distribution reflects abnormal flow dynamics or embolic injury.
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Affiliation(s)
- Arnold J Sansevere
- From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA.
| | - Melissa L DiBacco
- From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA
| | - Alireza Akhondi-Asl
- From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA
| | - Kerri LaRovere
- From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA
| | - Tobias Loddenkemper
- From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA
| | - Michael J Rivkin
- From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA
| | - Ravi R Thiagarajan
- From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA
| | - Phillip L Pearl
- From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA
| | - Mark H Libenson
- From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA
| | - Robert C Tasker
- From the Division of Epilepsy and Neurophysiology (A.J.S., M.L.D., T.L. , P.L.P., M.H.L.), Department of Anesthesiology, Critical Care and Pain Medicine (A.A.-A., R.C.T.), Department of Neurology (K.L., T.L., M.J.R., P.L.P., M.H.L., R.C.T.), Department of Psychiatry and Radiology (M.J.R.), and Department of Cardiology, Division of Cardiovascular Critical Care (R.R.T.), Boston Children's Hospital, MA
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Prevalence of Seizures in Pediatric Extracorporeal Membrane Oxygenation Patients as Measured by Continuous Electroencephalography. Pediatr Crit Care Med 2018; 19:1162-1167. [PMID: 30247227 DOI: 10.1097/pcc.0000000000001730] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Standards for neuromonitoring during extracorporeal membrane oxygenation support do not currently exist, and there is wide variability in practice. We present our institutional experience at an academic children's hospital since establishment of a continuous electroencephalography monitoring protocol for extracorporeal membrane oxygenation patients. DESIGN Retrospective, single-center study. SETTING Neonatal ICU and PICU in an urban, quaternary care center. PATIENTS All neonatal and pediatric patients requiring extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, 70 patients were cannulated for extracorporeal membrane oxygenation and had continuous electroencephalography monitoring for greater than 24 hours. Electroencephalographic seizures were observed in 16 of 70 patients (23%), including five patients (7%) who were in status epilepticus. Among patients with continuous electroencephalography seizures, nine (56%) had subclinical nonconvulsive status epilepticus and eight (50%) had seizures in the initial 24 hours of extracorporeal membrane oxygenation support. Survival to hospital discharge was significantly greater for extracorporeal membrane oxygenation patients without seizures (74% vs 44%; p = 0.02). CONCLUSIONS Seizures occur in a significant proportion of pediatric and neonatal extracorporeal membrane oxygenation patients, frequently in the initial 24 hours after extracorporeal membrane oxygenation cannulation. Because seizures are associated with significantly decreased survival, neuromonitoring early in the extracorporeal membrane oxygenation course is important and useful. Further studies are needed to correlate electroencephalography findings with neurologic outcome.
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LaRovere KL, Vonberg FW, Prabhu SP, Kapur K, Harini C, Garcia-Jacques R, Chao JH, Akhondi-Asl A, Thiagarajan R, Tasker RC. Patterns of Head Computed Tomography Abnormalities During Pediatric Extracorporeal Membrane Oxygenation and Association With Outcomes. Pediatr Neurol 2017; 73:64-70. [PMID: 28662916 DOI: 10.1016/j.pediatrneurol.2017.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/10/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND We sought to classify type and distribution of acute infarction and hemorrhage on head computed tomography (CT) during pediatric extracorporeal membrane oxygenation (ECMO). We also analyzed the occurrence of seizures on electroencephalography and outcomes between those with and without CT abnormalities. METHODS We conducted a single center observational study in pediatric intensive care units. The medical records of 179 children who underwent ECMO between 2009 and 2013 were reviewed. No interventions were done. RESULTS A total of 46% (82/179) of children underwent CT. Of these, 60% (49/82) had acute pathology. Cerebral infarction occurred in 55% (27/49) and hemorrhage in 41% (20/49). Infarction was arterial in 67% (18/27) with a preponderance in the middle cerebral artery territory (17 patients). Infarction was bilateral in 41% (11/27) and not specific to the side of cannulation in the rest. Sensitivity and specificity for head ultrasound in predicting infarction on CT were 100% and 53%, respectively. A total of 36% (65/179) underwent continuous encephalography monitoring; 22% (14/65) of these had electrographic seizures. Electrographic seizures were increased in those with infarction (odds ratio [OR], 6.81; 95% confidence interval [CI], 1.98 to 23.43). Survival was reduced with both infarction (OR, 0.22; 95% CI, 0.09 to 0.54) and hemorrhage (OR, 0.31; 95% CI, 0.13 to 0.72). Children with CT abnormalities had more unfavorable outcomes (P = 0.01). CONCLUSIONS Head ultrasound is insufficient to rule out infarction. Infarction is middle cerebral artery predominant and associated with an increased risk of electrographic seizures.
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Affiliation(s)
- Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Frederick W Vonberg
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sanjay P Prabhu
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kush Kapur
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Chellamani Harini
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rogelio Garcia-Jacques
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jessica H Chao
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aliresa Akhondi-Asl
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ravi Thiagarajan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert C Tasker
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Abstract
OBJECTIVE We aimed to determine the prevalence and risk factors for electrographic seizures in neonates and children requiring extracorporeal membrane oxygenation support. DESIGN Prospective quality improvement project. SETTING Quaternary care pediatric institution. PATIENTS Consistent with American Clinical Neurophysiology Society electroencephalographic monitoring recommendations, neonates and children requiring extracorporeal membrane oxygenation support underwent clinically indicated electroencephalographic monitoring. INTERVENTIONS We performed a 2-year quality improvement study from July 2013 to June 2015 evaluating electrographic seizure prevalence and risk factors. MAIN RESULTS Ninety-nine of 112 patients (88%) requiring extracorporeal membrane oxygenation support underwent electroencephalographic monitoring. Electrographic seizures occurred in 18 patients (18%), of whom 11 patients (61%) had electrographic status epilepticus and 15 patients (83%) had exclusively electrographic-only seizures. Electrographic seizures were more common in patients with low cardiac output syndrome (p = 0.03). Patients with electrographic seizures were more likely to die prior to discharge (72% vs 30%; p = 0.01) and have unfavorable outcomes (54% vs 17%; p = 0.004) than those without electrographic seizures. CONCLUSIONS Electrographic seizures occurred in 18% of neonates and children requiring extracorporeal membrane oxygenation support, often constituted electrographic status epilepticus, and were often electrographic-only thereby requiring electroencephalographic monitoring for identification. Low cardiac output syndrome was associated with an increased risk for electrographic seizures. Electrographic seizures were associated with higher mortality and unfavorable outcomes. Further investigation is needed to determine whether electrographic seizures identification and management improves outcomes.
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A review of long-term EEG monitoring in critically ill children with hypoxic-ischemic encephalopathy, congenital heart disease, ECMO, and stroke. J Clin Neurophysiol 2013; 30:134-42. [PMID: 23545764 DOI: 10.1097/wnp.0b013e3182872af9] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Continuous EEG monitoring is being used with increasing frequency in critically ill children with hypoxic ischemic encephalopathy, congenital heart disease, stroke, and extracorporeal membrane oxygenation (ECMO). The primary indication for EEG monitoring is to identify electrographic seizures and electrographic status epilepticus, which have been associated with worse outcome in some populations. A secondary indication is to provide prognostic information. This review summarizes the available data regarding continuous EEG monitoring in critically ill children with special attention to hypoxic ischemic encephalopathy, congenital heart disease, stroke, and children undergoing ECMO.
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Glial fibrillary acidic protein as a brain injury biomarker in children undergoing extracorporeal membrane oxygenation. Pediatr Crit Care Med 2011; 12:572-9. [PMID: 21057367 PMCID: PMC3686089 DOI: 10.1097/pcc.0b013e3181fe3ec7] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether, in children, plasma glial fibrillary acidic protein is associated with brain injury during extracorporeal membrane oxygenation and with mortality. DESIGN Prospective, observational study. SETTING Pediatric intensive care unit in an urban tertiary care academic center. PATIENTS Neonatal and pediatric patients on extracorporeal membrane oxygenation (n = 22). INTERVENTIONS Serial blood sampling for glial fibrillary acidic protein measurements. MEASUREMENTS AND MAIN RESULTS Prospective patients age 1 day to 18 yrs who required extracorporeal membrane oxygenation from April 2008 to August 2009 were studied. Glial fibrillary acidic protein was measured using an electrochemiluminescent immunoassay developed at Johns Hopkins. Control samples were collected from 99 healthy children (0.5-16 yrs) and 59 neonatal intensive care unit infants without neurologic injury. In controls, the median glial fibrillary acidic protein concentration was 0.055 ng/mL (interquartile range, 0-0.092 ng/mL) and the 95th percentile of glial fibrillary acidic protein was 0.436 ng/mL. In patients on extracorporeal membrane oxygenation, plasma glial fibrillary acidic protein was measured at 6, 12, and every 24 hrs after cannulation. We enrolled 22 children who underwent extracorporeal membrane oxygenation. Median age was 7 days (interquartile range, 2 days to 9 yrs), and primary extracorporeal membrane oxygenation indication was: cardiac failure, six of 22 (27.3%); respiratory failure, 12 of 22 (54.5%); extracorporeal cardiopulmonary resuscitation, three of 22 (13.6%); and sepsis, one of 22 (4.6%). Seven of 22 (32%) patients developed acute neurologic injury (intracranial hemorrhage, brain death, or cerebral edema diagnosed by imaging). Fifteen of 22 (68%) survived to hospital discharge. In the extracorporeal membrane oxygenation group, peak glial fibrillary acidic protein levels were higher in children with brain injury than those without (median, 5.9 vs. 0.09 ng/mL, p = .04) and in nonsurvivors compared with survivors to discharge (median, 5.9 vs. 0.09 ng/mL, p = .04). The odds ratio for brain injury for glial fibrillary acidic protein >0.436 ng/mL vs. normal was 11.5 (95% confidence interval, 1.3-98.3) and the odds ratio for mortality was 13.6 (95% confidence interval, 1.7-108.5). CONCLUSIONS High glial fibrillary acidic protein during extracorporeal membrane oxygenation is significantly associated with acute brain injury and death. Brain injury biomarkers may aid in outcome prediction and neurologic monitoring of patients on extracorporeal membrane oxygenation to improve outcomes and benchmark new therapies.
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Horan M, Azzopardi D, Edwards AD, Firmin RK, Field D. Lack of influence of mild hypothermia on amplitude integrated-electroencephalography in neonates receiving extracorporeal membrane oxygenation. Early Hum Dev 2007; 83:69-75. [PMID: 16814962 DOI: 10.1016/j.earlhumdev.2006.05.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 04/28/2006] [Accepted: 05/04/2006] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To observe amplitude integrated electroencephalography (aEEG) in neonates receiving ECMO and to determine whether mild hypothermia influenced the aEEG recording. METHODS Twenty-six consecutive neonates enrolled in a pilot study of mild hypothermia during ECMO were studied. The first group (N=6) was maintained at 37 degrees C throughout the study period. Subsequent groups were cooled to 36 degrees C (N=4), 35 degrees C (N=5), and finally 34 degrees C (N=6) respectively for 24 h and the final group (N=5) to 34 degrees C for 48 h before being rewarmed to 37 degrees C. The aEEG was recorded continuously during the first 5 days of ECMO. The aEEG was classified as normal, moderately or severely suppressed and examined for the occurrence of seizures. To assess the effect of temperature, the aEEG was compared over 12 h during the final 6 h of cooling and during the first 6 h once infants were rewarmed. RESULTS No change in aEEG amplitude was noted over the temperature range studied. Of the 26 traces obtained, 16 (62%) were normal throughout, 6 (23%) were intermittently moderately abnormal and 1 (14%) was severely abnormal. Three (11%) traces had periods of frequent seizure activity and these were not associated with clinical manifestations in two neonates. In one infant who suffered a cerebral haemorrhage, the aEEG became abnormal before cranial ultrasound abnormalities were apparent. CONCLUSIONS Continuous cerebral monitoring with aEEG is feasible during ECMO and may add information to clinical examination. Mild hypothermia to 34 degrees C for up to 48 h does not influence the aEEG suggesting that cerebral monitoring with aEEG is possible during mild hypothermia.
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Affiliation(s)
- Marie Horan
- The Department of Child Health, University of Leicester, Leicester, UK.
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Trittenwein G, Plenk S, Mach E, Mostafa G, Boigner H, Burda G, Hermon M, Golej J, Pollak A. Quantitative Electroencephalography Values of Neonates During and After Venoarterial Extracorporeal Membrane Oxygenation and Permanent Ligation of Right Common Carotid Artery. Artif Organs 2006; 30:447-51. [PMID: 16734596 DOI: 10.1111/j.1525-1594.2006.00240.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Venoarterial extracorporeal membrane oxygenation (ECMO) in neonates commonly needs neck vessel cannulation leading to ligation of right common carotid artery (RCCA) in some cases. Quantitative electroencephalography (EEG) measurements provide reproducible data of cerebral function. The aim of this case-control study was to test whether ligation of the RCCA results in EEG changes after ECMO weaning. Ten mechanically ventilated neonates not treated with ECMO were eligible as control patients. Seven ECMO patients receiving similar sedoanalgesia were investigated during and after ECMO and RCCA ligation. Dominant frequency, absolute alpha, theta, delta, and total powers of right and left frontocentral and temporooccipital derivations were calculated. Dominant frequency did not differ among groups. Power was found to be significantly decreased in all frequency bands during ECMO. After weaning from ECMO, EEG differences between the ECMO and control groups disappeared in spite of permanent RCCA ligation. It is concluded that ligation of the RCCA per se does not result in quantitative EEG changes.
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Affiliation(s)
- Gerhard Trittenwein
- Pediatric Intensive Care Unit, University Children's Hospital, Vienna, Austria.
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Pappas A, Shankaran S, Stockmann PT, Bara R. Changes in amplitude-integrated electroencephalography in neonates treated with extracorporeal membrane oxygenation: a pilot study. J Pediatr 2006; 148:125-7. [PMID: 16423612 DOI: 10.1016/j.jpeds.2005.07.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Revised: 06/30/2005] [Accepted: 07/27/2005] [Indexed: 11/20/2022]
Abstract
Neonates (n = 20) treated with extracorporeal membrane oxygenation were evaluated with serial amplitude-integrated electroencephalography (aEEG). There was no acute change in aEEG during extracorporeal membrane oxygenation cannulation, nor were there lateralizing effects. An abnormal aEEG predicted death or moderate to severe intracranial neuropathology with sensitivity = 1.0, specificity = 0.75, positive predictive value = 0.86, and negative predictive value = 1.0.
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Affiliation(s)
- Athina Pappas
- Neonatal-Perinatal Medicine Department, Wayne State University School of Medicine, Detroit, Michigan, USA.
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Amigoni A, Pettenazzo A, Biban P, Suppiej A, Freato F, Zaramella P, Zacchello F. Neurologic outcome in children after extracorporeal membrane oxygenation: prognostic value of diagnostic tests. Pediatr Neurol 2005; 32:173-9. [PMID: 15730897 DOI: 10.1016/j.pediatrneurol.2004.10.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2004] [Accepted: 10/21/2004] [Indexed: 10/25/2022]
Abstract
This report presents the long-term (36 months) neurologic outcome in 12 neonates and 9 children who survived after extracorporeal membrane oxygenation and attempts to identify its prognostic indicators through a prospective study in the pediatric intensive care unit of a university hospital. Outcome assessment, neurodevelopmental tests, electroencephalogram, auditory evoked potentials, visual evoked potentials, and somatosensory evoked potentials, cerebral sonography, or cerebral tomography were evaluated at the end of bypass and at 6, 12, 24, and 36 months after extracorporeal membrane oxygenation. "Before extracorporeal membrane oxygenation" variables (oxygenation index, pH, oxygen arterial partial pressure) and "during extracorporeal membrane oxygenation" variables (pH, oxygen arterial partial pressure, duration of bypass, clotting activated time, electroencephalogram) were also analyzed. A negative neurologic outcome (Glasgow Outcome Score different from "good recovery" or neurodevelopmental score less than 70) 12 months after extracorporeal membrane oxygenation was documented in 8.3% of neonates and in 30% of children who survived. There was no further change in subsequent evaluations (24 and 36 months follow-up). The most abnormal electroencephalogram during extracorporeal membrane oxygenation, the first electroencephalogram, neuroimaging score, and somatosensory evoked potentials after extracorporeal membrane oxygenation treatment were associated with negative neurologic outcome. The study documented that neonates and children treated with extracorporeal membrane oxygenation require long-term follow-up; electroencephalogram, neuroimaging score, and somatosensory evoked potentials have prognostic value for abnormal neurologic outcome.
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Affiliation(s)
- Angela Amigoni
- Department of Paediatrics, University of Padua, Via Giustiniani 3, 35128 Padua, Italy
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Douglass LM, Wu JY, Rosman NP, Stafstrom CE. Burst suppression electroencephalogram pattern in the newborn: predicting the outcome. J Child Neurol 2002; 17:403-8. [PMID: 12174958 DOI: 10.1177/088307380201700601] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A neonatal burst suppression electroencephalogram (EEG) is usually associated with an ominous prognosis. It is controversial whether a reactive burst suppression pattern (ie, a burst suppression pattern that can be interrupted by stimulation) is predictive of a better outcome. We retrospectively studied 22 full-term newborns with burst suppression EEGs to examine their functional outcome. Follow-up (3 to 9 years) was by record review and telephone interview. On the basis of initial EEG pattern and prognosis, three groups were identified post hoc: group 1 (n = 16) had initially nonreactive burst suppression EEGs that remained abnormal; 11 patients died, 4 remained profoundly impaired (nonambulatory, nonverbal), and 1 was moderately impaired (unassisted ambulation, limited speech). Group 2 (n = 3) had initially nonreactive burst suppression EEGs that later improved substantially (within a mean of 7 weeks). At follow-up (3 to 8 1/2 years), each child was waLking (one with braces), talking, and enrolled in special education. Group 3 (n = 3) had reactive burst suppression EEGs initially. At follow-up (ages 3 1/2 to 9 years), each child was walking unassisted and speaking in sentences. Two children in group 3 were of preschool age, and the third was in a special needs program. Although most newborns with nonreactive burst suppression EEGs have a dire neurologic outcome, of those in whom the EEG improves early, the prognosis may be slightly more favorable. Infants with reactive burst suppression EEGs during the acute phase of illness appear to have the best prognosis.
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Affiliation(s)
- Laurie M Douglass
- Division of Pediatric Neurology, The Floating Hospital for Children at New England Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA.
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Gannon CM, Kornhauser MS, Gross GW, Wiswell TE, Baumgart S, Streletz LJ, Graziani LJ, Spitzer AR. When combined, early bedside head ultrasound and electroencephalography predict abnormal computerized tomography or magnetic resonance brain images obtained after extracorporeal membrane oxygenation treatment. J Perinatol 2001; 21:451-5. [PMID: 11894513 DOI: 10.1038/sj.jp.7210593] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Definitive neuroimaging of the brain using computerized tomography (CT) or magnetic resonance imaging (MRI) in extracorporeal membrane oxygenation (ECMO)-treated infants must be delayed until after this therapy is completed. Bedside head ultrasound (HUS) and electroencephalography (EEG) studies during ECMO, if highly correlated with later definitive neuroimaging, might be used to affect the acute clinical care and early parental counseling of infants with severe cardiorespiratory failure. One hundred and sixty ECMO-treated patients had both bedside EEG and HUS studies performed during ECMO, as well as a later CT or MRI study prior to hospital discharge. There was a significant difference in CT or MRI findings among patients having normal studies on both the HUS and EEG, compared to those having an abnormality on either the HUS or the EEG, and compared to those having abnormalities on both studies. In ECMO-treated infants, the combination of a normal bedside HUS and an EEG without marked abnormalities is highly predictive of normal post-ECMO CT and MRI neuroimaging studies.
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Affiliation(s)
- C M Gannon
- Departments of Pediatrics, Radiology, and Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Goodman M, Gringlas M, Baumgart S, Stanley C, Desai SA, Turner M, Streletz LJ, Graziani LJ. Neonatal electroencephalogram does not predict cognitive and academic achievement scores at early school age in survivors of neonatal extracorporeal membrane oxygenation. J Child Neurol 2001; 16:745-50. [PMID: 11669348 DOI: 10.1177/088307380101601007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracorporeal membrane oxygenation is an effective rescue treatment for severe cardiorespiratory failure in term or near-term neonates, although a wide range of neurologic sequelae have been noted in a substantial minority of survivors. The objective of the present study was to determine the value of the neonatal electroencephalogram (EEG) for predicting Wechler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), Wide Range Achievement Test, and Wide Range Assessment of Memory and Language scores at early school age in 66 testable survivors of extracorporeal membrane oxygenation who were not severely brain damaged. Technically satisfactory EEG recordings were obtained at least twice following admission to our nursery and prior to discharge. The EEGs were classified and graded according to standard criteria. The developmental test results of those who had only normal or mildly abnormal neonatal EEGs (group 1, n = 9) were compared with those who had at least one moderately or markedly abnormal recording (group 2, n = 57). School-age test and subtest scores were not statistically significantly worse in group 2 versus group 1 infants. No child in group 1 and five children in group 2 had WPPSI-R Full-Scale IQ scores of less than 70. Of the nine children in group 2 who had at least one markedly abnormal neonatal EEG recording (graded as burst suppression or as electrographic seizure), only two had abnormally low WPPSI-R Full-Scale IQ scores. We conclude that EEG recordings obtained during the neonatal course of neonates treated with extracorporeal membrane oxygenation do not predict cognitive and academic achievement test results in survivors at early school age who were testable and not severely brain damaged.
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Affiliation(s)
- M Goodman
- Department of Pediatrics, Thomas Jefferson University, Jefferson Medical College, Philadelphia, PA 19107, USA.
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Baumgart S, Graziani LJ. Predicting the future for term infants experiencing an acute neonatal encephalopathy: electroencephalogram, magnetic resonance imaging, or crystal ball? Pediatrics 2001; 107:588-9. [PMID: 11230604 DOI: 10.1542/peds.107.3.588] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- S Baumgart
- State University of New York at Stony Brook, Stony Brook, NY 11794-8111, USA.
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Biagioni E, Mercuri E, Rutherford M, Cowan F, Azzopardi D, Frisone MF, Cioni G, Dubowitz L. Combined use of electroencephalogram and magnetic resonance imaging in full-term neonates with acute encephalopathy. Pediatrics 2001; 107:461-8. [PMID: 11230583 DOI: 10.1542/peds.107.3.461] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The electroencephalogram (EEG) is widely used in full-term infants with acute neonatal encephalopathy, and its prognostic value has been confirmed by several studies. Magnetic resonance imaging (MRI) of the brain has also been applied in these patients, and increasing numbers of reports affirm its prognostic reliability. The aim of this study has been to investigate the correlation between an early EEG and MRI findings in infants with acute neonatal encephalopathy and to assess the prognostic value of a combination of EEG and MRI findings. PARTICIPANTS AND METHODS Twenty-five full-term infants had an EEG recorded within the first 72 hours after birth and a neonatal brain MRI scan after the end of the first week. RESULTS Both EEG and MRI were predictive of outcome. A normal MRI was always associated with normal EEG background activity and normal outcome and severe abnormalities on MRI with marked EEG abnormalities and an abnormal outcome. When the MRI showed moderate abnormalities, the EEG in all cases but one identified patients with normal and abnormal outcome.EEG, MRI, HIE, neurodevelopment.
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Affiliation(s)
- E Biagioni
- Department of Paediatrics and Neonatal Medicine, Imperial College School of Medicine, Hammersmith Hospital, London, United Kingdom
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Biagioni E, Bartalena L, Boldrini A, Pieri R, Cioni G. Constantly discontinuous EEG patterns in full-term neonates with hypoxic-ischaemic encephalopathy. Clin Neurophysiol 1999; 110:1510-5. [PMID: 10479016 DOI: 10.1016/s1388-2457(99)00091-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Selected EEG features were evaluated in 21 constantly discontinuous tracings recorded on the same number of full-term neonates with hypoxic-ischaemic encephalopathy. METHODS The tracings were examined without using interval amplitude as the basis for distinguishing between burst-suppression and nonburst-suppression patterns. RESULTS The results were related to outcomes and other clinical parameters (severity of hypoxic-ischaemic encephalopathy, pO2 levels and drug intake). CONCLUSIONS Features defining the grade of EEG discontinuity (i.e. maximum interval duration, minimum burst duration and interval amplitude) significantly related to outcome and, in most cases, to the grade of hypoxic-ischaemic encephalopathy. Other features (amplitude of slow waves within the burst and incidence of abnormal EEG transients) related to PO2 levels. The consumption of anticonvulsant drugs increased EEG discontinuity, but this effect did not seem dose-related. Finally, the persistence of a constantly discontinuous EEG pattern after the first week of life is a sign of unfavourable prognosis. In full-term neonates with hypoxic-ischaemic encephalopathy quantitative analysis of all constantly discontinuous EEGs seems more useful than only describing burst-suppression patterns on the basis of interval amplitude.
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Affiliation(s)
- E Biagioni
- Stella Maris Scientific Institute, Division of Child Neurology and Psychiatry, University of Pisa, Italy.
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Graziani LJ, Baumgart S, Desai S, Stanley C, Gringlas M, Spitzer AR. Clinical antecedents of neurologic and audiologic abnormalities in survivors of neonatal extracorporeal membrane oxygenation. J Child Neurol 1997; 12:415-22. [PMID: 9373797 DOI: 10.1177/088307389701200702] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Extracorporeal membrane oxygenation is an effective rescue treatment for severe cardiorespiratory failure in term or near term neonates, although cerebral palsy, mental retardation, and sensorineural hearing loss are observed in 10 to 20% of survivors. The objective of the present study was to identify potential risk factors that may explain the neurologic and audiologic sequelae noted in 19% of 181 survivors of neonatal extracorporeal membrane oxygenation from our hospital. Our results suggest the following findings in survivors of severe cardiorespiratory failure treated with neonatal extracorporeal membrane oxygenation: (1) hypotension or the need for cardiopulmonary resuscitation before extracorporeal membrane oxygenation significantly increases the risk of spastic cerebral palsy, (2) profound hypocarbia before extracorporeal membrane oxygenation is associated with a significantly increased risk of hearing loss, (3) mental retardation in the absence of spastic cerebral palsy is unexplained except when due to abnormal fetal brain development, and (4) hypoxemia in the absence of hypotension does not increase the risk of neurologic or audiologic sequelae.
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Affiliation(s)
- L J Graziani
- Department of Pediatrics, Thomas Jefferson University, Jefferson Medical College, Philadelphia, PA, USA
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The effects of morphine and midazolam on EEGs in neonates. J Clin Neurosci 1997; 4:173-5. [DOI: 10.1016/s0967-5868(97)90069-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/1995] [Accepted: 03/24/1995] [Indexed: 11/22/2022]
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