1
|
Sandelich S, Hooley G, Hsu G, Rose E, Ruttan T, Schwarz ES, Simon E, Sulton C, Wall J, Dietrich AM. Acute opioid overdose in pediatric patients. J Am Coll Emerg Physicians Open 2024; 5:e13134. [PMID: 38464332 PMCID: PMC10920943 DOI: 10.1002/emp2.13134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/13/2024] [Indexed: 03/12/2024] Open
Abstract
Recent increases in pediatric and adolescent opioid fatalities mandate an urgent need for early consideration of possible opioid exposure and specific diagnostic and management strategies and interventions tailored to these unique populations. In contrast to adults, pediatric methods of exposure include accidental ingestions, prescription misuse, and household exposure. Early recognition, appropriate diagnostic evaluation, along with specialized treatment for opioid toxicity in this demographic are discussed. A key focus is on Naloxone, an essential medication for opioid intoxication, addressing its unique challenges in pediatric use. Unique pediatric considerations include recognition of accidental ingestions in our youngest population, critical social aspects including home safety and intentional exposure, and harm reduction strategies, mainly through Naloxone distribution and education on safe medication practices. It calls for a multifaceted approach, including creating pediatric-specific guidelines, to combat the opioid crisis among children and to work to lower morbidity and mortality from opioid overdoses.
Collapse
Affiliation(s)
- Stephen Sandelich
- Department of Emergency MedicinePenn State College of MedicinePenn State Milton S. Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Gwen Hooley
- Department of Emergency MedicineChildren's Hospital of Los AngelesLos AngelesCaliforniaUSA
| | - George Hsu
- Department of Emergency MedicineAugusta University‐Medical College of GeorgiaAugustaGeorgiaUSA
| | - Emily Rose
- Department of Emergency MedicineKeck School of Medicine of the University of Southern CaliforniaLos Angeles General Medical CenterLos AngelesCaliforniaUSA
| | - Tim Ruttan
- Department of PediatricsDell Medical SchoolThe University of Texas at AustinUS Acute Care SolutionsCantonOhioUSA
| | - Evan S. Schwarz
- Division of Medical ToxicologyDepartment of Emergency MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Erin Simon
- Department of Emergency MedicineCleveland ClinicAkronOhioUSA
| | - Carmen Sulton
- Departments of Pediatrics and Emergency MedicineEmory University School of MedicineChildren's Healthcare of Atlanta, EglestonAtlantaGeorgiaUSA
| | - Jessica Wall
- Departments of Pediatrics and Emergency MedicineSeattle Children's HospitalHarborview Medical CenterSeattleWashingtonUSA
| | - Ann M Dietrich
- Department of Emergency MedicinePrisma HealthGreenvilleSouth CarolinaUSA
| |
Collapse
|
2
|
Basco WT, Bundy DG, Garner SS, Ebeling M, Simpson KN. Annual Prevalence of Opioid Receipt by South Carolina Medicaid-Enrolled Children and Adolescents: 2000-2020. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095681. [PMID: 37174201 PMCID: PMC10178489 DOI: 10.3390/ijerph20095681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/15/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023]
Abstract
Understanding patterns of opioid receipt by children and adolescents over time and understanding differences between age groups can help identify opportunities for future opioid stewardship. We conducted a retrospective cohort study, using South Carolina Medicaid data for children and adolescents 0-18 years old between 2000-2020, calculating the annual prevalence of opioid receipt for medical diagnoses in ambulatory settings. We examined differences in prevalence by calendar year, race/ethnicity, and by age group. The annual prevalence of opioid receipt for medical diagnoses changed significantly over the years studied, from 187.5 per 1000 in 2000 to 41.9 per 1000 in 2020 (Cochran-Armitage test for trend, p < 0.0001). In all calendar years, older ages were associated with greater prevalence of opioid receipt. Adjusted analyses (logistic regression) assessed calendar year differences in opioid receipt, controlling for age group, sex, and race/ethnicity. In the adjusted analyses, calendar year was inversely associated with opioid receipt (aOR 0.927, 95% CI 0.926-0.927). Males and older ages were more likely to receive opioids, while persons of Black race and Hispanic ethnicity had lower odds of receiving opioids. While opioid receipt declined among all age groups during 2000-2020, adolescents 12-18 had persistently higher annual prevalence of opioid receipt when compared to younger age groups.
Collapse
Affiliation(s)
- William T Basco
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - David G Bundy
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - Sandra S Garner
- Department of Clinical Pharmacy and Outcome Sciences, College of Pharmacy, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - Myla Ebeling
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kit N Simpson
- Department of Healthcare Leadership & Management, College of Health Professions, The Medical University of South Carolina, Charleston, SC 29425, USA
| |
Collapse
|
3
|
Rosen DM, Alcock MM, Palmer GM. Opioids for acute pain management in children. Anaesth Intensive Care 2022; 50:81-94. [PMID: 35172638 DOI: 10.1177/0310057x211065769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Opioids are integral to multimodal analgesic regimens in children with moderate to severe acute pain. Throughout normal childhood there are marked changes in physiology, and social and psychological development that influence the perception and expression of pain, the pharmacology of opioids, and how they are used. A multidimensional pain assessment is key to guiding appropriate opioid prescribing. Most of the commonly used opioids in adults are used in children, with the increasing exception of codeine (as a result of regulatory change), and are generally well tolerated. Patient groups at increased risk of ventilatory impairment include neonates and those with obstructive sleep apnoea, severe neurodevelopmental conditions, trisomy 21, and severe epilepsy. Slow-release opioids are not recommended for general use, but may be used in select populations, for example, following scoliosis surgery, major trauma or burns. Prescribing and administration errors are a major issue in paediatrics generally; the potential consequences of opioid prescribing or administration errors are serious, particularly following hospital discharge. Opioids prescribed at discharge are frequently in excess of a child's analgesic requirements; three to five days supply appears sufficient for the majority of common paediatric operations. Discharge opioid prescriptions have been linked to long-term opioid use in adolescents with risk factors. Misuse of prescription opioids by adolescents is also concerning, with prevalence estimates ranging from 1.1% to 20%. Caregivers have a tendency to underdose opioids in their children; caregiver education may improve appropriate administration. Caregivers must also be provided with instructions on safe storage and disposal of unused opioids.
Collapse
Affiliation(s)
- Derek M Rosen
- Department of Anaesthesia and Pain Management, Queensland Children's Hospital, Brisbane, Queensland, Australia.,University of Queensland, Queensland, Brisbane, Australia
| | - Mark M Alcock
- Department of Anaesthesia and Pain Management, Queensland Children's Hospital, Brisbane, Queensland, Australia.,University of Queensland, Queensland, Brisbane, Australia
| | - Greta M Palmer
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
4
|
Heins SE, Buttorff C, Armstrong C, Pacula RL. Claims-based measures of prescription opioid utilization: A practical guide for researchers. Drug Alcohol Depend 2021; 228:109087. [PMID: 34598101 PMCID: PMC8595838 DOI: 10.1016/j.drugalcdep.2021.109087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/14/2021] [Accepted: 08/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given the increased attention to the opioid epidemic and the role of inappropriate prescribing, there has been a marked increase in the number of studies using claims data to study opioid use and policies designed to curb misuse. Our objective is to review the medical literature for recent studies that use claims data to construct opioid use measures and to develop a guide for researchers using these measures. METHODS We searched for articles relating to opioid use measured in health insurance claims data using a defined set of search terms for the years 2014-2020. Original research articles based in the United States that used claims-based measures of opioid utilization were included and information on the study population and measures of any opioid use, quantity of opioid use, new opioid use, chronic opioid use, multiple providers, and overlapping prescriptions was abstracted. RESULTS A total of 164 articles met inclusion criteria. Any opioid use was the most commonly included measure, defined by 85 studies. This was followed by quantity of opioids (68 studies), chronic opioid use (53 studies), overlapping prescriptions (28 studies), and multiple providers (8 studies). Each measure contained multiple, distinct definitions with considerable variation in how each was operationalized. CONCLUSIONS Claims-based opioid utilization measures are commonly used in research, but definitions vary significantly from study to study. Researchers should carefully consider which opioid utilization measures and definitions are most appropriate for their study and recognize how different definitions may influence study results.
Collapse
Affiliation(s)
| | | | | | - Rosalie Liccardo Pacula
- RAND Corporation, Santa Monica, CA, USA,Schaeffer Center for Health Policy & Economics, University of Southern California
| |
Collapse
|
5
|
Chua KP, Brummett CM, Conti RM, Bohnert AS. Opioid Prescribing to US Children and Young Adults in 2019. Pediatrics 2021; 148:peds.2021-051539. [PMID: 34400571 PMCID: PMC8778996 DOI: 10.1542/peds.2021-051539] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Recent national data are lacking on the prevalence, safety, and prescribers of opioid prescriptions dispensed to children and young adults aged 0 to 21 years. METHODS We identified opioid prescriptions dispensed to children and young adults in 2019 in the IQVIA Longitudinal Prescription Database, which captures 92% of US pharmacies. We calculated the proportion of all US children and young adults with ≥1 dispensed opioid prescription in 2019. We calculated performance on 6 metrics of high-risk prescribing and the proportion of prescriptions written by each specialty. Of all prescriptions and those classified as high risk by ≥1 metric, we calculated the proportion written by high-volume prescribers with prescription counts at the ≥95th percentile. RESULTS Analyses included 4 027 701 prescriptions. In 2019, 3.5% of US children and young adults had ≥1 dispensed opioid prescription. Of prescriptions for opioid-naive patients, 41.8% and 3.8% exceeded a 3-day and 7-day supply, respectively. Of prescriptions for young children, 8.4% and 7.7% were for codeine and tramadol. Of prescriptions for adolescents and young adults, 11.5% had daily dosages of ≥50 morphine milligram equivalents; 4.6% had benzodiazepine overlap. Overall, 45.6% of prescriptions were high risk by ≥1 metric. Dentists and surgeons wrote 61.4% of prescriptions. High-volume prescribers wrote 53.3% of prescriptions and 53.1% of high-risk prescriptions. CONCLUSIONS Almost half of pediatric opioid prescriptions are high risk. To reduce high-risk prescribing, initiatives targeting high-volume prescribers may be warranted. However, broad-based initiatives are also needed to address the large share of high-risk prescribing attributable to other prescribers.
Collapse
Affiliation(s)
- Kao-Ping Chua
- Division of General Pediatrics, Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Chad M. Brummett
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI,Michigan Opioid Prescribing Engagement Network, Ann Arbor, MI
| | - Rena M. Conti
- Department of Markets, Public Policy, And Law, Institute for Health System Innovation and Policy, Questrom School of Business, Boston University, Boston, MA
| | - Amy S. Bohnert
- Division of Pain Medicine, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI,VA Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI
| |
Collapse
|
6
|
Phang KG, Roberts JR, Ebeling M, Garner SS, Basco WT. Opioids or Steroids for Pneumonia or Sinusitis. Pediatrics 2020; 146:peds.2019-3690. [PMID: 32616629 PMCID: PMC7397734 DOI: 10.1542/peds.2019-3690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To compare the frequency of opioid and corticosteroid prescriptions dispensed for children with pneumonia or sinusitis visits on the basis of location of care. METHODS We evaluated 2016 South Carolina Medicaid claims data for 5 to 18 years olds with pneumonia or sinusitis. Visits were associated with 1 of 3 locations: the emergency department (ED), urgent care, or the ambulatory setting. RESULTS Inclusion criteria were met by 31 838 children. Pneumonia visits were more often linked to an opioid prescription in the ED (34 of 542 [6.3%]) than in ambulatory settings (24 of 1590 [1.5%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (106 of 542 [19.6%]) than in ambulatory settings (196 of 1590 [12.3%]; P ≤ .0001). Sinusitis visits were more often linked to an opioid prescription in the ED (202 of 2705 [7.5%]) than in ambulatory settings (568 of 26 866 [2.1%]; P ≤ .0001) and were more frequently linked to a steroid prescription in the ED (510 of 2705 [18.9%]) than in ambulatory settings (1922 of 26 866 [7.2%]; P ≤ .0001). In logistic regression for children with pneumonia, the ED setting was associated with increased odds of receiving an opioid (adjusted odds ratio [aOR] 4.69) or steroid (aOR 1.67). Similarly, patients with sinusitis were more likely to be prescribed opioids (aOR 4.02) or steroids (aOR 3.05) in the ED than in ambulatory sites. CONCLUSIONS School-aged children received opioid and steroid prescriptions for pneumonia or sinusitis at a higher frequency in the ED versus the ambulatory setting.
Collapse
Affiliation(s)
| | - James R. Roberts
- Medical University of South Carolina, Charleston, South Carolina
| | - Myla Ebeling
- Medical University of South Carolina, Charleston, South Carolina
| | - Sandra S. Garner
- Medical University of South Carolina, Charleston, South Carolina
| | - William T. Basco
- Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
7
|
Risk Factors for Electronic Prescription Errors in Pediatric Intensive Care Patients. Pediatr Crit Care Med 2020; 21:557-562. [PMID: 32343112 DOI: 10.1097/pcc.0000000000002303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess risk factors for electronic prescription errors in a PICU. DESIGN A database of electronic prescriptions issued by a computerized physician order entry with clinical decision support system was analyzed to identify risk factors for prescription errors. MEASUREMENTS AND MAIN RESULTS Of 6,250 prescriptions, 101 were associated with errors (1.6%). The error rate was twice as high in patients older than 12 years than in patients children 6-12 and 0-6 years old (2.4% vs 1.3% and 1.2%, respectively, p < 0.05). Compared with patients without errors, patients with errors had a significantly higher score on the Pediatric Index of Mortality 2 (-3.7 vs -4.5; p = 0.05), longer PICU stay (6 vs 3.1 d; p < 0.0001), and higher number of prescriptions per patient (40.8 vs. 15.7; p < 0.0001). In addition, patients with errors were more likely to have a neurologic main admission diagnosis (p = 0.008) and less likely to have a cardiologic diagnosis (p = 0.03) than patients without errors. CONCLUSIONS Our findings suggest that older patient age and greater disease severity are risk factors for electronic prescription errors.
Collapse
|
8
|
Sears K, Elms S, Whitehead M, Tranmer JE, Edge DS, VanDenKerkhof EG. A population-based study of prescribing trends in a potentially vulnerable paediatric population from 1999 to 2012. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 27:545-554. [PMID: 31373071 DOI: 10.1111/ijpp.12565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 05/20/2019] [Accepted: 07/03/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES There is a limited understanding of paediatric medication prescribing trends and patterns, thus poorly positioning decision-makers to identify quality and safety concerns related to medication use. The objective of this study was to determine overall medication prescribing trends and patterns among children receiving Ontario Drug Benefits over a thirteen-year period in the province of Ontario, Canada. METHODS Administrative health databases housed within the Institute for Clinical Evaluative Sciences (ICES), Ontario, Canada, were used to identify outpatient prescriptions dispensed from 1999 to 2012 through a publicly funded programme to children ≤18 years of age. Medications were classified according to the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system. Descriptive statistics were used to summarize prescribing patterns. KEY FINDINGS This study identified 457 037 children who were dispensed a new prescription between 1999 and 2012. About 56% received their first prescription before 6.5 years of age, and 85% of the children in this study were from families who received social assistance. The most commonly prescribed drugs were antiinfectives (56.1%). Prescriptions for several central nervous system agents, including antipsychotics and agents for attention-deficit/hyperactivity disorder, increased across the study period. Changes in prescribing patterns within opioids, hormones and autonomic agents were noted. The results suggest that historically, prescribing trends have shifted with public policy, pharmaceutical marketing and diagnostic patterns, thus identifying them as a possible tool to measure the impact of policydriven practice changes. Anti-infective prescribing increased markedly with the global H1N1 pandemic. Pharmaceutical marketing, formulary decisions and diagnostic trends may affect the prescribing of ADHD medications globally. The prescribing of codeine-containing products and medroxyprogesterone appeared to fluctuate in response to important publications in the medical literature, and the use of epinephrine syringes increased after public policy changes in the province of Ontario. The steady rise in the use of medications whose long-term effects in children are unknown, such as antipsychotics and proton pump inhibitors, identifies areas in need of future research. CONCLUSIONS This study presents the first overview of Canadian prescribing trends for children, the majority of which are of low socioeconomic status and represent a potentially vulnerable population. Our analysis suggests that future research is required to determine whether prescribing trends could be used as indicators of policy effectiveness, pharmacovigilance and diagnostic trends.
Collapse
Affiliation(s)
- Kim Sears
- School of Nursing, Queen's University, Kingston, ON, Canada
| | - Sherri Elms
- School of Nursing, Queen's University, Kingston, ON, Canada
| | - Marlo Whitehead
- Institute for Clinical Evaluative Sciences, Queen's University, Kingston, ON, Canada
| | - Joan E Tranmer
- School of Nursing, Queen's University, Kingston, ON, Canada.,Institute for Clinical Evaluative Sciences, Queen's University, Kingston, ON, Canada
| | - Dana S Edge
- School of Nursing, Queen's University, Kingston, ON, Canada
| | - Elizabeth G VanDenKerkhof
- School of Nursing, Queen's University, Kingston, ON, Canada.,Institute for Clinical Evaluative Sciences, Queen's University, Kingston, ON, Canada
| |
Collapse
|
9
|
Basco WT, Roberts JR, Ebeling M, Garner SS, Hulsey TC, Simpson K. Indications for Use of Combination Acetaminophen/Opioid Drugs in Infants <6 Months Old. Clin Pediatr (Phila) 2018; 57:741-744. [PMID: 28891326 PMCID: PMC5858976 DOI: 10.1177/0009922817730349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | | | - Myla Ebeling
- The Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Kit Simpson
- The Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
10
|
Dautremont EA, Ebramzadeh E, Beck JJ, Bowen RE, Sangiorgio SN. Opioid Prescription and Usage in Adolescents Undergoing Orthopaedic Surgery in the United States: A Systematic Review. JBJS Rev 2018; 5:e5. [PMID: 28796696 DOI: 10.2106/jbjs.rvw.16.00093] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The proper use of opioid analgesia for postoperative pain management is controversial. While opioids are considered the standard of care for multimodal postoperative pain modulation in the United States, there is a lack of established protocols for prescribing opioids in adolescents undergoing outpatient orthopaedic surgery. The objective of this review was to identify and report on current literature on opioid prescription for pain management in adolescents undergoing all procedures, as well as in adults undergoing outpatient orthopaedic surgery. METHODS A comprehensive literature search using PRISMA guidelines was performed to identify all articles relevant to opioid use in adolescents for postoperative pain and in adults following outpatient orthopaedic procedures. RESULTS A total of 4,446 results were identified from databases and relevant journal web sites. Of these, 9 articles were selected that fit the criteria for review. Five studies discussed the dosage and type of opioids prescribed in adolescent populations, and 4 quantified patient self-administration in adult populations. CONCLUSIONS Adolescent opioid pain management following outpatient orthopaedic surgery is not documented. Current recommendations for opioid prescription in adolescents lack support and are primarily based on adult dosages. Adult studies suggest that opioid medications may be overprescribed following outpatient orthopaedic surgery. These results clearly indicate that there is a pressing need for quantitative research on pain management following outpatient orthopaedic surgery in the adolescent population in the United States. CLINICAL RELEVANCE There appear to be no studies on self-administered opioid pain medication following orthopaedic surgery in an adolescent population, suggesting that there is no objective basis for the current prescription recommendations.
Collapse
Affiliation(s)
- Erin A Dautremont
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center (E.A.D., E.E., and S.N.S.), Orthopaedic Institute for Children (J.J.B. and R.E.B.), in alliance with the Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California.,College of Osteopathic Medicine, Touro University Nevada, Henderson, Nevada
| | - Edward Ebramzadeh
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center (E.A.D., E.E., and S.N.S.), Orthopaedic Institute for Children (J.J.B. and R.E.B.), in alliance with the Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Jennifer J Beck
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center (E.A.D., E.E., and S.N.S.), Orthopaedic Institute for Children (J.J.B. and R.E.B.), in alliance with the Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Richard E Bowen
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center (E.A.D., E.E., and S.N.S.), Orthopaedic Institute for Children (J.J.B. and R.E.B.), in alliance with the Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Sophia N Sangiorgio
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center (E.A.D., E.E., and S.N.S.), Orthopaedic Institute for Children (J.J.B. and R.E.B.), in alliance with the Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California
| |
Collapse
|