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Tasker RC. Editor's Choice Articles for April. Pediatr Crit Care Med 2024; 25:285-287. [PMID: 38573038 DOI: 10.1097/pcc.0000000000003501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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McCabe BC, Morrison WE, Morgan RW, Himebauch AS. Admission Functional Status is Associated With Intensivists Perception of Extracorporeal Membrane Oxygenation Candidacy for Pediatric Acute Respiratory Failure. Pediatr Crit Care Med 2024; 25:354-361. [PMID: 38099731 DOI: 10.1097/pcc.0000000000003428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVES To determine the association between admission Functional Status Scale (FSS) category and perceived extracorporeal membrane oxygenation (ECMO) candidacy for pediatric acute respiratory failure. DESIGN Prospective, cross-sectional study. SETTING Single-center, quaternary, and ECMO referral academic children's hospital between March 2021 and January 2022. SUBJECTS Pediatric intensivists directly caring for patients admitted with acute respiratory failure secondary to shock or respiratory disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pediatric intensivists were surveyed about current patients within 72 hours of initiation or escalation of invasive mechanical ventilation on whether they would offer ECMO should their patient deteriorate. Baseline functional status was assessed using trichotomized admission FSS: 1) normal/mild dysfunction (6-9), 2) moderate dysfunction (10-15), and 3) severe dysfunction (> 16). Multivariable logistic regression clustered by physician was used to assess the association between admission FSS category with perceived ECMO candidacy. Thirty-seven intensivists participated with 76% (137/180) of survey responses by those with less than 10 years of experience. 81% of patients (146/180) were perceived as ECMO candidates and 19% of patients (34/180) were noncandidates. Noncandidates had worse admission FSS scores than candidates (15.5 vs. 9, p < 0.001). After adjustment for age, admission FSS category of severe dysfunction had lower odds of perceived ECMO candidacy compared with normal to mild dysfunction (odds ratio [OR] 0.18 [95% CI, 0.06-0.56], p < 0.003). Patients with an abnormal communication subscore domain had the lowest odds of being considered a candidate (unadjusted OR 0.44 [95% CI, 0.29-0.68], p < 0.0001). CONCLUSIONS In this prospective, single-center, cross-sectional study, admission FSS category indicating worse baseline functional status impacted pediatric intensivists' perceptions of ECMO candidacy for patients with acute respiratory failure. Abnormal FSS subscores in the neurocognitive domains were the most important considerations. Future studies should better seek to define the decision-making priorities of both parents and medical specialists for the utilization of ECMO in children with acute respiratory failure.
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Affiliation(s)
- Brenna C McCabe
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA
- Division of Pediatric Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center and Morgan Stanley Children's Hospital, New York, NY
| | - Wynne E Morrison
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, The Justin Michael Ingerman Center for Pediatric Palliative Care, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ryan W Morgan
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Adam S Himebauch
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA
- ECMO Center, The Children's Hospital of Philadelphia, Philadelphia, PA
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Rogerson CM, Rowan CM. Critical Care Utilization in Children With Cancer: U.S. Pediatric Health Information System Database Cohort 2012-2021. Pediatr Crit Care Med 2024; 25:e52-e58. [PMID: 37812031 PMCID: PMC10840865 DOI: 10.1097/pcc.0000000000003380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
OBJECTIVES To determine changes in pediatric oncology hospitalizations requiring intensive care over the period 2012-2021. DESIGN Retrospective study of hospital admission. SETTING Registry data from 36 children's hospitals in the U.S. Pediatric Health Information Systems database. PATIENTS Children 18 years or younger admitted to any of 36 hospitals with an oncology diagnosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were a total of 55,827 unique patients accounted for 281,221 pediatric oncology hospitalizations over the 10-year period, and 16.6% of hospitalizations included admission to the PICU. Hospitalizations and PICU admissions steadily increased over this decade. Between 2012 and 2016, 15.1% of oncology hospitalizations were admitted to the PICU compared with 18.0% from 2017 to 2021 (difference 2.9% [95% CI, 2.6-3.2%] p ≤ 0.0001). Support with invasive mechanical ventilation also increased over time with 3.7% during 2012-2016 compared with 4.1% from 2017 to 2021 (difference 0.4% [95% CI, 0.2-0.5%] p ≤ 0.0001). Similar results were seen with cardiorespiratory life support using extracorporeal membrane oxygenation (difference 0.05% [95% CI, 0.02-0.07%] p = 0.0002), multiple vasoactive agent use (difference 0.3% [95% CI, 0.2-0.4%] p < 0.0001), central line placement (difference 5.3% [95% CI, 5.1-5.6%], p < 0.001), and arterial line placement (difference 0.4% [95% CI, 0.3-0.4%], p < 0.001). Year-on-year case fatality rate was unchanged over time (1.3%), but admission to the PICU during the second 5 years, compared with the first 5 years, was associated with lower odds of mortality (difference 0.7% [95% CI, 0.3-1.1%]) (odds ratio 0.82 [95% CI, 0.75-0.90%] p < 0.001). CONCLUSIONS The percentage of pediatric oncology hospitalizations resulting in PICU admission has increased over the past 10 years. Despite the increasing use of PICU admission and markers of acuity, and on comparing 2017-2021 with 2012-2016, there are lower odds of mortality.
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Affiliation(s)
- Colin M Rogerson
- Both authors: Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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Extracorporeal Membrane Oxygenation in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S124-S134. [PMID: 36661441 DOI: 10.1097/pcc.0000000000003164] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To systematically review and assimilate literature on children receiving extracorporeal membrane oxygenation (ECMO) support in pediatric acute respiratory distress syndrome (PARDS) with the goal of developing an update to the Pediatric Acute Lung Injury Consensus Conference recommendations and statements about clinical practice and research. DATA SOURCES Electronic searches of MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION The search used a medical subject heading terms and text words to capture studies of ECMO in PARDS or acute respiratory failure. Studies using animal models and case reports were excluded from our review. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. There were 18 studies identified for full-text extraction. When pediatric data was lacking, adult and neonatal data from randomized clinical trials and observational studies were considered. Six clinical recommendations were generated related to ECMO indications, initiation, and management in PARDS. There were three good practice statements generated related to ECMO indications, initiation, and follow-up in PARDS. Two policy statements were generated involving the impact of ECMO team organization and training in PARDS. Last, there was one research statement. CONCLUSIONS Based on a systematic literature review, we propose clinical management, good practice and policy statements within the domains of ECMO indications, initiation, team organization, team training, management, and follow-up as they relate to PARDS.
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The Use of Extracorporeal Membrane Oxygenation as a Bridge to Bone Marrow Transplantation in a Patient With High-risk Acute Myeloid Leukemia. J Pediatr Hematol Oncol 2023; 45:18-20. [PMID: 36219701 DOI: 10.1097/mph.0000000000002567] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/10/2022] [Indexed: 02/02/2023]
Abstract
An 18-year-old girl with high-risk acute myeloid leukemia developed Streptococcus mitis septic shock and multiorgan dysfunction syndrome, including biventricular failure. Due to the anticipated reversibility of her cardiogenic shock, her young age, and her favorable survival chance after an allogeneic hematopoietic stem cell transplant, she was placed on full circulatory support with venoarterial extracorporeal membrane oxygenation as a bridge to her successful hematopoietic stem cell transplantation 2 months later. This highlights the importance of prognostication in patient selection for extracorporeal life support. A multidisciplinary approach is essential to each case until more definite initiation criteria, risk stratification, and treatment protocols are established.
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Agulnik A, Mahadeo KM, Steiner ME, McArthur JA. Editorial: Critical complications in pediatric oncology and hematopoietic cell transplant - how far we have come and how much further we must go. Front Oncol 2023; 13:1148321. [PMID: 36910613 PMCID: PMC9992885 DOI: 10.3389/fonc.2023.1148321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 02/24/2023] Open
Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, United States.,Division of Critical Care, Department of Pediatrics, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Kris M Mahadeo
- Division of Pediatric Transplantation and Cellular Therapy, Duke University School of Medicine, Durham, NC, United States
| | - Marie E Steiner
- Division of Pediatric Hematology Oncology, M Health Fairview Masonic Children's Hospital, Minneapolis, MN, United States
| | - Jennifer Ann McArthur
- Division of Critical Care, Department of Pediatrics, St. Jude Children's Research Hospital, Memphis, TN, United States
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Logan GE, Miller K, Kohler ME, Loi M, Maddux AB. Outcomes of Critically Ill Children With Acute Lymphoblastic Leukemia and Cytokine Release Syndrome Due to Chimeric Antigen Receptor T Cell Therapy: US, Multicenter PICU, Cohort Database Study. Pediatr Crit Care Med 2022; 23:e595-e600. [PMID: 36194016 PMCID: PMC9722524 DOI: 10.1097/pcc.0000000000003079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Cytokine release syndrome (CRS) is a potentially lethal toxicity associated with chimeric antigen receptor T cell therapy for pediatric acute lymphoblastic leukemia (ALL). Outcomes after critical illness due to severe CRS are poorly described. Our aim was to characterize critical illness outcomes across a multicenter cohort of PICU patients with ALL and CRS. DESIGN Multicenter retrospective cohort study. SETTING Twenty-one PICUs contributing data to Virtual Pediatric Systems, LLC (January 2020-December 2021). PATIENTS PICU patients with ALL or unclassified leukemia and CRS. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 55 patients; 34 (62%) were 12 years or older, 48 (87%) were admitted from a hospital inpatient ward, and 23 (42%) received advanced organ failure support or monitoring. Fifty-one survived to PICU discharge (93%) including 19 of 23 (83%) who received advanced organ failure support or monitoring defined as receipt of noninvasive or invasive ventilation, cardiopulmonary resuscitation, extracorporeal membrane oxygenation, continuous renal replacement therapy, or placement of a tracheostomy, arterial catheter, hemodialysis catheter, or intracranial catheter. Twelve patients (22%) received invasive ventilation, nine of whom survived to PICU discharge. Two of four patients who received continuous renal replacement therapy and one of three patients who required cardiopulmonary resuscitation survived to PICU discharge. Lengths of PICU stay were median 3.0 days (interquartile range, 1.4-7.8 d) among PICU survivors, 7.8 (5.4-11.1) among those receiving advanced organ failure support or monitoring, and 7.2 days (interquartile range, 2.9-14.7 d) among nonsurvivors. Of the 51 patients who survived to PICU discharge, 48 (94%) survived the hospitalization. CONCLUSIONS PICU patients with CRS frequently received a high level of support, and the majority survived their PICU stay and hospitalization. Additional multicenter investigations of severe CRS are necessary to inform evidence-based practice.
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Affiliation(s)
- Grace E. Logan
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Kristen Miller
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - M. Eric Kohler
- Department of Pediatrics, Section of Hematology and Oncology, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Michele Loi
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
- Department of Pediatrics, Section of Hematology and Oncology, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
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Randolph AG, Bembea MM, Cheifetz IM, Curley MAQ, Flori HR, Khemani RG, Kudchadkar SR, Nishisaki A, Watson RS, Tucci M, Lacroix J, Thompson AE, Thomas NJ. Pediatric Acute Lung Injury and Sepsis Investigators (PALISI): Evolution of an Investigator-Initiated Research Network. Pediatr Crit Care Med 2022; 23:1056-1066. [PMID: 36454002 PMCID: PMC9747245 DOI: 10.1097/pcc.0000000000003100] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network originated over 20 years ago to foster research to optimize the care of critically ill infants and children. Over this period, PALISI has seen two major evolutions: formalization of our network infrastructure and a broadening of our clinical research focus. First, the network is unique in that its activities and meetings are funded by subscriptions from members who now comprise a multidisciplinary group of investigators from over 90 PICUs all over the United States (US) and Canada, with collaborations across the globe. In 2020, the network converted into a standalone, nonprofit organizational structure (501c3), making the PALISI Network formally independent of academic and clinical institutions or professional societies. Such an approach allows us to invest in infrastructure and future initiatives with broader opportunities for fund raising. Second, our research investigations have expanded beyond the original focus on sepsis and acute lung injury, to incorporate the whole field of pediatric critical care, for example, efficient liberation from mechanical ventilator support, prudent use of blood products, improved safety of intubation practices, optimal sedation practices and glucose control, and pandemic research on influenza and COVID-19. Our network approach in each field follows, where necessary, the full spectrum of clinical and translational research, including: immunobiology studies for understanding basic pathologic mechanisms; surveys to explore contemporary clinical practice; consensus conferences to establish agreement about literature evidence; observational prevalence and incidence studies to measure scale of a clinical issue or question; case control studies as preliminary best evidence for design of definitive prospective studies; and, randomized controlled trials for informing clinical care. As a research network, PALISI and its related subgroups have published over 350 peer-reviewed publications from 2002 through September 2022.
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Affiliation(s)
- Adrienne G Randolph
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, MA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ira M Cheifetz
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
- Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Heidi R Flori
- Division of Critical Care Medicine, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Robinder G Khemani
- Division of Critical Care Medicine, Department of Anesthesia, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Akira Nishisaki
- Division of Critical Care Medicine, Department of Anesthesia, Children's Hospital of Philadelphia, Philadelphia, PA
| | - R Scott Watson
- Division of Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Marisa Tucci
- Division of Critical Care Medicine, CHU Sainte-Justine, Montreal, QC, Canada
| | - Jacques Lacroix
- Division of Critical Care Medicine, CHU Sainte-Justine, Montreal, QC, Canada
| | - Ann E Thompson
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Neal J Thomas
- Division of Critical Care Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
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Suzuki Y, Cass SH, Kugelmann A, Mobli K, Taylor WP, Radhakrishnan RS. Outcome of Extracorporeal Membrane Oxygenation for Pediatric Patients With Neoplasm: An Extracorporeal Life Support Organization Database Study (2000-2019). Pediatr Crit Care Med 2022; 23:e240-e248. [PMID: 35220342 DOI: 10.1097/pcc.0000000000002915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study update in usage and outcomes of pediatric extracorporeal membrane oxygenation (ECMO) for patients with neoplasm analyzed according to demographics, clinical variables, and complications. DESIGN Retrospective database review of the Extracorporeal Life Support Organization registry from the last 2 decades (2000-2019). The data were divided between two decades in order to compare patients' backgrounds and outcomes over time. SETTING ECMO centers reporting to Extracorporeal Life Support Organization. PATIENTS Patients equal to or younger than 18 years old with International Classification of Diseases, 9th Revision and International Classification of Diseases, 10th Revision codes that referred to neoplasms who were managed with ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographics, cancer subtype, clinical variables, and ECMO complications were assessed in relation to the primary study outcome of survival to hospital discharge. Nine-hundred two patients met inclusion criteria; 699 patients were in the latest decade, which is more than three times the number from the previous decade (203 patients). On univariate analysis, compared with the previous decade, in the later decade, ECMO was more frequently applied in patients with pre-ECMO cardiac arrest (31.3% vs 17.1%; p < 0.001), and/or lower oxygenation index (38.0 vs 48.1; p < 0.001). We failed to identify a difference in survival between the 2 decades (42.8% vs 37.9%; p = 0.218). On multivariable analysis, diagnosis of hematologic malignancy, post-cardiopulmonary resuscitation support type, hematopoietic stem cell transplant, and age older than seven were each associated with greater odds of mortality. CONCLUSIONS The use of ECMO in children with neoplasm has expanded over the latest decade with changes in patient selection. Mortality remains unchanged. Hence, although the clinician still should stay cautious in its application, ECMO can be considered as an option to rescue pediatric oncologic patients in the setting of worsening cardiopulmonary status in the PICU.
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Affiliation(s)
- Yota Suzuki
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Samuel H Cass
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | | | - Keyan Mobli
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Williams P Taylor
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Ravi S Radhakrishnan
- Division of Pediatric Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
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Tasker RC. Editor's Choice Articles for March. Pediatr Crit Care Med 2022; 23:149-150. [PMID: 35238840 DOI: 10.1097/pcc.0000000000002908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113.,Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.,Selwyn College, Cambridge University, Cambridge, United Kingdom
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