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de Morais DG, Sanches TRC, Santinho MAR, Yada EY, Segura GC, Lowe D, Navarro G, Seabra VF, Taniguchi LU, Malbouisson LMS, de André CDS, Andrade L, Rodrigues CE. Urinary sodium excretion is low prior to acute kidney injury in patients in the intensive care unit. FRONTIERS IN NEPHROLOGY 2022; 2:929743. [PMID: 37675036 PMCID: PMC10479577 DOI: 10.3389/fneph.2022.929743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/31/2022] [Indexed: 09/08/2023]
Abstract
Background The incidence of acute kidney injury (AKI) is high in intensive care units (ICUs), and a better understanding of AKI is needed. Early chronic kidney disease is associated with urinary concentration inability and AKI recovery with increased urinary solutes in humans. Whether the inability of the kidneys to concentrate urine and excrete solutes at appropriate levels could occur prior to the diagnosis of AKI is still uncertain, and the associated mechanisms have not been studied. Methods In this single-center prospective observational study, high AKI risk in ICU patients was followed up for 7 days or until ICU discharge. They were grouped as "AKI" or "No AKI" according to their AKI status throughout admission. We collected daily urine samples to measure solute concentrations and osmolality. Data were analyzed 1 day before AKI, or from the first to the fifth day of admission in the "No AKI" group. We used logistic regression models to evaluate the influence of the variables on future AKI diagnosis. The expression of kidney transporters in urine was evaluated by Western blotting. Results We identified 29 patients as "No AKI" and 23 patients as "AKI," the latter being mostly low severity AKI. Urinary sodium excretion was lower in "AKI" patients prior to AKI diagnosis, particularly in septic patients. The expression of Na+/H+ exchanger (NHE3), a urinary sodium transporter, was higher in "AKI" patients. Conclusions Urinary sodium excretion is low before an AKI episode in ICU patients, and high expressions of proximal tubule sodium transporters might contribute to this.
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Affiliation(s)
- David Gomes de Morais
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Talita Rojas Cunha Sanches
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Mirela Aparecida Rodrigues Santinho
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Yuki Yada
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Gabriela Cardoso Segura
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Diogo Lowe
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Guilherme Navarro
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Victor Faria Seabra
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Leandro Utino Taniguchi
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carmen Diva Saldiva de André
- Centro de Estatística Aplicada, Instituto de Matemática e Estatística, Universidade de São Paulo, São Paulo, Brazil
| | - Lúcia Andrade
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Camila Eleuterio Rodrigues
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Disciplina de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Association of Hypernatremia with Immune Profiles and Clinical Outcomes in Adult Intensive Care Unit Patients with Sepsis. Biomedicines 2022; 10:biomedicines10092285. [PMID: 36140385 PMCID: PMC9496274 DOI: 10.3390/biomedicines10092285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/05/2022] [Accepted: 09/12/2022] [Indexed: 11/17/2022] Open
Abstract
Both hypernatremia and an abnormal immune response may increase hospital mortality in patients with sepsis. This study examined the association of hypernatremia with abnormal immune response and mortality in 520 adult patients with sepsis in an intensive care unit (ICU). We compared the mortality and ex vivo lipopolysaccharide (LPS)-induced inflammatory response differences among patients with hyponatremia, eunatremia, and hypernatremia, as well as between patients with acquired hypernatremia on ICU day 3 and those with sustained eunatremia over first three ICU days. Compared with eunatremia or hyponatremia, hypernatremia led to higher 7 day, 14 day, 28 day, and hospital mortality rates (p = 0.030, 0.009, 0.010, and 0.033, respectively). Compared with sustained eunatremia, acquired hypernatremia led to higher 7, 14, and 28 day mortality rates (p = 0.019, 0.042, and 0.028, respectively). The acquired hypernatremia group nonsignificantly trended toward increased hospital mortality (p = 0.056). Day 1 granulocyte colony-stimulating factor (G-CSF) and tumor necrosis factor (TNF) α levels were relatively low in patients with hypernatremia (p = 0.020 and 0.010, respectively) but relatively high in patients with acquired hypernatremia (p = 0.049 and 0.009, respectively). Thus, in ICU-admitted septic patients, hypernatremia on admission and in ICU-acquired hypernatremia were both associated with higher mortality. The higher mortality in patients with hypernatremia on admission was possibly related to the downregulation of G-CSF and TNF-α secretion after endotoxin stimulation. Compared to sustained eunatremia, acquired hypernatremia showed immunoparalysis at first and then hyperinflammation on day 3.
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Mapata L, Richards GA, Laher AE. Hypernatremia at a Tertiary Hospital Intensive Care Unit in South Africa. Cureus 2022; 14:e22648. [PMID: 35371787 PMCID: PMC8962634 DOI: 10.7759/cureus.22648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/06/2022] Open
Abstract
Background Hypernatremia in the critical care setting is a major cause of morbidity and mortality. However, data pertaining to this has not been evaluated in South African hospitals. The aim of this study was to evaluate hypernatremia with regards to its prevalence, associated factors, and outcomes at an academic hospital intensive care unit (ICU) in Johannesburg, South Africa. Methods The ICU charts of patients admitted to the Charlotte Maxeke Johannesburg Academic Hospital adult general ICU from June 1, 2016 to May 31, 2017 were retrospectively reviewed. Subjects were categorized into three groups namely, ICU-acquired hypernatremia (IAH), pre-admission hypernatremia (PAH), and normonatremia. Data was compared between the three groups. Results Of the 833 subjects that were enrolled, 310 (37.2%) were hypernatremic. IAH was present in 144 (17.2%) and PAH in 166 (19.9%) subjects. Hypernatremia was significantly (p <0.05) associated with a higher rate of altered mental status, higher Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) scores, a higher rate and duration of mechanical ventilation, a greater need for inotropic/vasopressor support, longer ICU stay and higher ICU mortality. Conclusion Hypernatremia in ICU patients remains a significant contributor to morbidity, mortality, and ICU length of stay. The prevalence of hypernatremia was much higher than that reported in higher-income countries.
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Rugg C, Bachler M, Mösenbacher S, Wiewiora E, Schmid S, Kreutziger J, Ströhle M. Early ICU-acquired hypernatraemia is associated with injury severity and preceded by reduced renal sodium and chloride excretion in polytrauma patients. J Crit Care 2021; 65:9-17. [PMID: 34052781 DOI: 10.1016/j.jcrc.2021.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/12/2021] [Accepted: 05/15/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To further elucidate the origin of early ICU-acquired hypernatraemia. MATERIAL AND METHODS In this retrospective single-centre study, polytrauma patients requiring ICU treatment were analysed. RESULTS Forty-eight (47.5%) of 101 included polytrauma patients developed hypernatraemia within the first 7 days on ICU. They were more severely ill as described by higher SAPS III, ISS, daily SOFA scores and initial norepinephrine requirements as well as longer requirements of mechanical ventilation and ICU treatment in general. The development of hypernatraemia was neither attributable to fluid- or sodium-balances nor renal impairment. Although lower in the hypernatraemic group from day 4 onwards, median creatinine clearances were sufficiently high throughout the observation period. However, in the hypernatraemic group, urine sodium and chloride concentrations prior to the evolvement of hypernatraemia (56 (27-87) mmol/l and 39 (23-77) mmol/l) were significantly decreased when compared to i) the time after developing hypernatraemia (94 (58-134) mmol/l and 78 (36-115) mmol/l; p < 0.001) and ii) the non-hypernatraemic group in general (101 (66-143) mmol/l and 75 (47-109) mmol/l; p < 0.001). CONCLUSIONS Early ICU-acquired hypernatraemia is associated with injury severity and preceded by reduced renal sodium and chloride excretion in polytrauma patients.
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Affiliation(s)
- Christopher Rugg
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Mirjam Bachler
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Simon Mösenbacher
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Elena Wiewiora
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Stefan Schmid
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Janett Kreutziger
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Mathias Ströhle
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
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Renal Function is a Major Determinant of ICU-acquired Hypernatremia: A Balance Study on Sodium Handling. J Transl Int Med 2020; 8:165-176. [PMID: 33062593 PMCID: PMC7534501 DOI: 10.2478/jtim-2020-0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and Objectives The development of ICU-acquired hypernatremia (IAH) is almost exclusively attributed to ‘too much salt and too little water’. However, intrinsic mechanisms also have been suggested to play a role. To identify the determinants of IAH, we designed a prospective controlled study. Methods Patients with an anticipated length of stay ICU > 48 hours were included. Patients with hypernatremia on admission and/or on renal replacement therapy were excluded. Patients without IAH were compared with patients with borderline hypernatremia (≥ 143 mmol/L, IAH 143) and more severe hypernatremia (≥ 145 mmol/L, IAH 145). Results We included 89 patients, of which 51% developed IAH 143 and 29% IAH 145. Sodium intake was high in all patients. Fluid balances were slightly positive and comparable between the groups. Patients with IAH 145 were more severely ill on admission, and during admission, their sodium intake, cumulative sodium balances, serum creatinine and copeptin levels were higher. According to the free water clearance, all the patients conserved water. On multivariate analysis, the baseline serum creatinine was an independent risk factor for the development of IAH 143 and IAH 145. Also, the copeptin levels remained significant for IAH 143 and IAH 145. Sodium intake remained only significant for patients with IAH 145. Conclusions Our data support the hypothesis that IAH is due to the combination of higher sodium intake and a urinary concentration deficit, as a manifestation of the renal impairment elicited by severe illness.
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An observational study on intracutaneous sodium storage in intensive care patients and controls. PLoS One 2019; 14:e0223100. [PMID: 31581250 PMCID: PMC6776341 DOI: 10.1371/journal.pone.0223100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/13/2019] [Indexed: 11/19/2022] Open
Abstract
The development of ICU-acquired sodium disturbances is not fully understood. Alterations in non-osmotic skin sodium storage, hypothetically inflammation-driven, could play a role. To investigate this in critically ill patients we conducted a patient-control study with skin punch biopsies in patients with sepsis (n = 15), after coronary artery bypass grafting (CABG, n = 15) and undergoing total hip arthroplasty (THA-controls, n = 15) respectively, together representing a range in severity of systemic inflammation. Biopsies were taken within 24 hours (sepsis) and within 2 hours (CABG) after ICU-admission, and prior to arthroplasty. Biopsies were analysed for sodium content. In addition immunostainings and quantitative real time PCR were performed. The primary aim of this study was to detect possible differences in amounts of cutaneous sodium. The secondary aims were to quantify inflammation and lymphangiogenesis with concomitant markers. The highest amounts of both water and sodium were found in patients with sepsis, with slightly lower values after CABG and the lowest amounts in THA-controls. Correlation between water and sodium was 0.5 (p<0.01). In skin biopsies in all groups comparable amounts of macrophages, T-cells and lymph vessels were found. In all groups comparable expression of inflammation markers were found. However, higher mRNA transcript expression levels of markers of lymphangiogenesis were found in patients with sepsis and after CABG. The conjoint accumulation of water and sodium points towards oedema formation. However, the correlation coefficient of 0.5 leaves room for alternative explanations, including non-osmotic sodium storage. No signs of dermal inflammation were found, but upregulation of markers of lymphangiogenesis could indicate future lymphangiogenesis.
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De Freitas G, Gudur A, Vela-Ortiz M, Jodelka J, Livert D, Krishnamurthy M. Where there is sodium there may be sepsis. J Community Hosp Intern Med Perspect 2019; 9:296-299. [PMID: 31528275 PMCID: PMC6735289 DOI: 10.1080/20009666.2019.1634407] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/17/2019] [Indexed: 11/14/2022] Open
Abstract
Hypernatremia affects up to 9% of critically ill patients upon hospital admission, especially in elderly patients with thirst impairment. However, hypernatremia is not entirely explained by fluid imbalance. Recent studies suggest that sodium is an important enhancer of the immune system, raising the question of whether inflammatory states such as sepsis may contribute to hypernatremia. Although sepsis patients with hypernatremia face a greater mortality rate, there is a lack of studies examining a potential association between hypernatremia and sepsis. Motivated by the frequent concurrence of hypernatremia and sepsis observed at an eastern Pennsylvanian community hospital, the current study was conducted to evaluate whether hypernatremia on admission may serve as a potential surrogate marker for sepsis. The medical records of 153 patients with hypernatremia on admission (serum sodium > 145mEq/L) were retrospectively analyzed. The mean age of patients was 81.1. Sepsis was observed in 77.1% of patients, of which 86.2% had dementia. This study demonstrated a positive correlation between hypernatremia on admission and the presence of sepsis. We suggest that the existence of hypernatremia should prompt clinicians to further investigate for sources of infection, especially in the elderly and patients with dementia.
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Affiliation(s)
| | - Anuragh Gudur
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Jacek Jodelka
- St. Luke's University Hospital, Fountain Hill, PA, USA
| | - David Livert
- Internal Medicine, Easton Hospital, Easton, PA, USA.,Drexel University College of Medicine, Philadelphia, PA, USA
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Hessels L, Oude Lansink-Hartgring A, Zeillemaker-Hoekstra M, Nijsten MW. Estimation of sodium and chloride storage in critically ill patients: a balance study. Ann Intensive Care 2018; 8:97. [PMID: 30306364 PMCID: PMC6179979 DOI: 10.1186/s13613-018-0442-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/03/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Nonosmotic sodium storage has been reported in animals, healthy individuals and patients with hypertension, hyperaldosteronism and end-stage kidney disease. Sodium storage has not been studied in ICU patients, who frequently receive large amounts of sodium chloride-containing fluids. The objective of our study was to estimate sodium that cannot be accounted for by balance studies in critically ill patients. Chloride was also studied. We used multiple scenarios and assumptions for estimating sodium and chloride balances. METHODS We retrospectively analyzed patients admitted to the ICU after cardiothoracic surgery with complete fluid, sodium and chloride balance data for the first 4 days of ICU treatment. Balances were obtained from meticulously recorded data on intake and output. Missing extracellular osmotically active sodium (MES) was calculated by subtracting the expected change in plasma sodium from the observed change in plasma sodium derived from balance data. The same method was used to calculate missing chloride (MEC). To address considerable uncertainties on the estimated extracellular volume (ECV) and perspiration rate, various scenarios were used in which the size of the ECV and perspiration were varied. RESULTS A total of 38 patients with 152 consecutive ICU days were analyzed. In our default scenario, we could not account for 296 ± 35 mmol of MES in the first four ICU days. The range of observed MES in the five scenarios varied from 111 ± 27 to 566 ± 41 mmol (P < 0.001). A cumulative value of 243 ± 46 mmol was calculated for MEC in the default scenario. The range of cumulative MEC was between 62 ± 27 and 471 ± 56 mmol (P = 0.001 and P = 0.003). MES minus MEC varied from 1 ± 51 to 123 ± 33 mmol in the five scenarios. CONCLUSIONS Our study suggests considerable disappearance of osmotically active sodium in critically ill patients and is the first to also suggest rather similar disappearance of chloride from the extracellular space. Various scenarios for insensible water loss and estimated size for the ECV resulted in considerable MES and MEC, although these estimates showed a large variation. The mechanisms and the tissue compartments responsible for this phenomenon require further investigation.
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Affiliation(s)
- Lara Hessels
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Annemieke Oude Lansink-Hartgring
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Miriam Zeillemaker-Hoekstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.,Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten W Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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Quinn JW, Sewell K, Simmons DE. Recommendations for active correction of hypernatremia in volume-resuscitated shock or sepsis patients should be taken with a grain of salt: A systematic review. SAGE Open Med 2018; 6:2050312118762043. [PMID: 29593868 PMCID: PMC5865456 DOI: 10.1177/2050312118762043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 02/06/2018] [Indexed: 12/22/2022] Open
Abstract
Background: Healthcare-acquired hypernatremia (serum sodium >145 mEq/dL) is common among critically ill and other hospitalized patients and is usually treated with hypotonic fluid and/or diuretics to correct a “free water deficit.” However, many hypernatremic patients are eu- or hypervolemic, and an evolving body of literature emphasizes the importance of rapidly returning critically ill patients to a neutral fluid balance after resuscitation. Objective: We searched for any randomized- or observational-controlled studies evaluating the impact of active interventions intended to correct hypernatremia to eunatremia on any outcome in volume-resuscitated patients with shock and/or sepsis. Data sources: We performed a systematic literature search with studies identified by searching MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, Index-Catalogue of the Library of the Surgeon General’s Office, DARE (Database of Reviews of Effects), and CINAHL and scanning reference lists of relevant articles with abstracts published in English. Data synthesis: We found no randomized- or observational-controlled trials measuring the impact of active correction of hypernatremia on any outcome in resuscitated patients. Conclusion: Recommendations for active correction of hypernatremia in resuscitated patients with sepsis or shock are unsupported by clinical research acceptable by modern evidence standards.
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Affiliation(s)
- Joseph W Quinn
- Department of Emergency Medicine, East Carolina University, Greenville, NC, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, East Carolina University, Greenville, NC, USA
| | | | - Dell E Simmons
- Department of Emergency Medicine, East Carolina University, Greenville, NC, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, East Carolina University, Greenville, NC, USA
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