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Mensink HA, Desai A, Cvetkovic M, Davidson M, Hoskote A, O'Callaghan M, Thiruchelvam T, Roeleveld PP. The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO. Perfusion 2024; 39:81S-94S. [PMID: 38651582 DOI: 10.1177/02676591241236139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Extracorporeal Cardiopulmonary Resuscitation (ECPR) has potential benefits compared to conventional Cardiopulmonary Resuscitation (CCPR) in children. Although no randomised trials for paediatric ECPR have been conducted, there is extensive literature on survival, neurological outcome and risk factors for survival. Based on current literature and guidelines, we suggest recommendations for deployment of paediatric ECPR emphasising the requirement for protocols, training, and timely intervention to enhance patient outcomes. Factors related to outcomes of paediatric ECPR include initial underlying rhythm, CCPR duration, quality of CCPR, medications during CCPR, cannulation site, acidosis and renal dysfunction. Based on current evidence and experience, we provide an approach to patient selection, ECMO initiation and management in ECPR regarding blood and sweep flow settings, unloading of the left ventricle, diagnostics whilst on ECMO, temperature targets, neuromonitoring as well as suggested weaning and decannulation strategies.
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Affiliation(s)
- H A Mensink
- Paediatric Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - A Desai
- Paediatric Intensive Care, Royal Brompton Hospital, London, UK
| | - M Cvetkovic
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - M Davidson
- Critical Care Medicine, Royal Hospital for Children, Glasgow, UK
| | - A Hoskote
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - M O'Callaghan
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - T Thiruchelvam
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - P P Roeleveld
- Paediatric Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
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Seeber F, Krenner N, Sames-Dolzer E, Tulzer A, Srivastava I, Kreuzer M, Mair R, Gierlinger G, Nawrozi MP, Mair R. Outcome after extracorporeal membrane oxygenation therapy in Norwood patients before the bidirectional Glenn operation. Eur J Cardiothorac Surg 2024; 65:ezae153. [PMID: 38603622 DOI: 10.1093/ejcts/ezae153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/26/2024] [Accepted: 04/09/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVES Patients after the Norwood procedure are prone to postoperative instability. Extracorporeal membrane oxygenation (ECMO) can help to overcome short-term organ failure. This retrospective single-centre study examines ECMO weaning, hospital discharge and long-term survival after ECMO therapy between Norwood and bidirectional Glenn palliation as well as risk factors for mortality. METHODS In our institution, over 450 Norwood procedures have been performed. Since the introduction of ECMO therapy, 306 Norwood operations took place between 2007 and 2022, involving ECMO in 59 cases before bidirectional Glenn. In 48.3% of cases, ECMO was initiated intraoperatively post-Norwood. Patient outcomes were tracked and mortality risk factors were analysed using uni- and multivariable testing. RESULTS ECMO therapy after Norwood (median duration: 5 days; range 0-17 days) saw 31.0% installed under CPR. Weaning was achieved in 46 children (78.0%), with 55.9% discharged home after a median of 45 (36-66) days. Late death occurred in 3 patients after 27, 234 and 1541 days. Currently, 30 children are in a median 4.8 year (3.4-7.7) follow-up. At the time of inquiry, 1 patient awaits bidirectional Glenn, 6 are at stage II palliation, Fontan was completed in 22 and 1 was lost to follow-up post-Norwood. Risk factor analysis revealed dialysis (P < 0.001), cerebral lesions (P = 0.026), longer ECMO duration (P = 0.002), cardiac indication and lower body weight (P = 0.038) as mortality-increasing factors. The 10-year mortality probability after ECMO therapy was 48.5% (95% CI 36.5-62.9%). CONCLUSIONS ECMO therapy in critically ill patients after the Norwood operation may significantly improve survival of a patient cohort otherwise forfeited and give the opportunity for successful future-stage operations.
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Affiliation(s)
- Fabian Seeber
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
| | - Niklas Krenner
- Department of Cardiothoracic and Vascular Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
| | - Eva Sames-Dolzer
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
| | - Andreas Tulzer
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
- Department of Pediatric Cardiology, Kepler University Hospital, Krankenhausstraße 26-30, Linz 4020, Austria
| | - Ishita Srivastava
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
| | - Michaela Kreuzer
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
| | - Roland Mair
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
| | - Gregor Gierlinger
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
| | - Mohammad-Paimann Nawrozi
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
- Department of Cardiothoracic and Vascular Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
| | - Rudolf Mair
- Department of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Krankenhausstraße 9, Linz 4020, Austria
- Medical Faculty, Johannes Kepler University, Krankenhausstraße 5, Linz 4020, Austria
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Miller N, Sandhu HS, Anton-Martin P. "Extracorporeal membrane oxygenation outcomes in multisystem inflammatory syndrome of childhood - An extracorporeal life support organization registry study". Perfusion 2024:2676591231226290. [PMID: 38179967 DOI: 10.1177/02676591231226290] [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: 01/06/2024]
Abstract
Multisystem inflammatory disease in childhood (MIS-C) is a novel pediatric syndrome after a COVID-19 infection that causes systemic injury, with potential life-threatening hemodynamic compromise requiring Extracorporeal Membrane Oxygenation (ECMO) support. We performed an observational retrospective cohort study in children aged 0-18 years with MIS-C and non-MIS-C myocarditis on ECMO between January 2020 and December 2021, using the ELSO Registry database. We aimed to compare the outcomes of both populations and to identify factors for decreased survival in MIS-C patients on ECMO. The Extracorporeal Life Support Organization (ELSO) Registry reported 310 pediatric ECMO patients with MIS-C (56.1%) and non-MIS-C myocarditis (43.9%). No difference was found in survival to hospital discharge between groups (67.2% for MIS-C vs 69.1% for non-MIS-C myocarditis, p 0.725). Multivariable analysis demonstrated that ECPR and co-infection were significantly associated with decreased survival to hospital discharge in MIS-C patients (OR 0.138, p 0.01 and OR 0.44, p 0.02, respectively). Outcomes of children with MIS-C on ECMO support are similar to those of non-MIS-C myocarditis despite higher infectious, multiorgan dysfunction and respiratory complications accompanying COVID-19 infections. The use of ECMO for MIS-C patients seems to be feasible and safe. Prospective studies on the use of ECMO support in MIS-C patients may improve outcomes in this pediatric population.
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Affiliation(s)
- Noah Miller
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital Memphis, Memphis, TN, USA
| | - Hitesh S Sandhu
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Le Bonheur Children's Hospital Memphis, Memphis, TN, USA
| | - Pilar Anton-Martin
- Division of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Zhou J, Wang H, Zhao Y, Shao J, Jiang M, Yue S, Lin L, Wang L, Xu Q, Guo X, Li X, Liu Z, Chen Y, Zhang R. Short-Term Mortality Among Pediatric Patients With Heart Diseases Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2023; 12:e029571. [PMID: 38063152 PMCID: PMC10863771 DOI: 10.1161/jaha.123.029571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 11/08/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation serves as a crucial mechanical circulatory support for pediatric patients with severe heart diseases, but the mortality rate remains high. The objective of this study was to assess the short-term mortality in these patients. METHODS AND RESULTS We systematically searched PubMed, Embase, and Cochrane Library for observational studies that evaluated the short-term mortality of pediatric patients undergoing veno-arterial extracorporeal membrane oxygenation. To estimate short-term mortality, we used random-effects meta-analysis. Furthermore, we conducted meta-regression and binomial regression analyses to investigate the risk factors associated with the outcome of interest. We systematically reviewed 28 eligible references encompassing a total of 1736 patients. The pooled analysis demonstrated a short-term mortality (defined as in-hospital or 30-day mortality) of 45.6% (95% CI, 38.7%-52.4%). We found a significant difference (P<0.001) in mortality rates between acute fulminant myocarditis and congenital heart disease, with acute fulminant myocarditis exhibiting a lower mortality rate. Our findings revealed a negative correlation between older age and weight and short-term mortality in patients undergoing veno-arterial extracorporeal membrane oxygenation. Male sex, bleeding, renal damage, and central cannulation were associated with an increased risk of short-term mortality. CONCLUSIONS The short-term mortality among pediatric patients undergoing veno-arterial extracorporeal membrane oxygenation for severe heart diseases was 45.6%. Patients with acute fulminant myocarditis exhibited more favorable survival rates compared with those with congenital heart disease. Several risk factors, including male sex, bleeding, renal damage, and central cannulation contributed to an increased risk of short-term mortality. Conversely, older age and greater weight appeared to be protective factors.
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Affiliation(s)
- Jingjing Zhou
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Haiming Wang
- Department of EndocrinologyChinese PLA Central Theater Command General HospitalWuhanChina
| | - Yunzhang Zhao
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Junjie Shao
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Min Jiang
- Department of Respiratory and Critical CareThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Shuai Yue
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Lejian Lin
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Lin Wang
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Qiang Xu
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Xinhong Guo
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Xin Li
- Department of Health ServicesThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Zifan Liu
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Yundai Chen
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Ran Zhang
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
- State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
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Zens T, Eldredge RS, Gill M, Mathew S, Molitor M. Vascular Reconstruction After Cannulation for Support With Extracorporeal Membrane Oxygenation: Literature Review of Data in the Pediatric Population. Pediatr Crit Care Med 2023; 24:1072-1083. [PMID: 37796088 DOI: 10.1097/pcc.0000000000003372] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) is an invaluable life-support resource in the treatment of critically ill children. Traditionally, neck vascular cannulation requires ligation of the carotid artery and jugular vein. In this literature review, we identify rates of postoperative vessel patency, complications, and neurologic outcomes after vascular reconstruction following decannulation. DATA SOURCES Embase, PubMed, and Cochrane Review. STUDY SELECTION No publication date limits. Inclusion criteria comprised of studies addressing repair of the carotid artery and jugular vein after ECMO decannulation and outcomes from this procedure. DATA EXTRACTION Authors identified publications on vascular reconstruction after ECMO decannulation, including possible technical considerations, complications, and outcomes. DATA SYNTHESIS We identified 18 articles: 13 studies were limited to the neonatal population. The largest series included 51 patients after vascular reconstruction. The rate of postoperative arterial occlusion ranged from 11.8% to 17.8%, and overall patency rate postoperatively was 78.6%. No major thromboembolic events were reported. One study demonstrated an increase in neuroimaging abnormalities for patients undergoing ligation compared with vascular reconstruction. No studies demonstrated differences in functional neurodevelopmental testing. CONCLUSIONS Vascular reconstruction after ECMO decannulation has been reported since 1990. Although reconstruction does not appear to carry significant short-term morbidity, there are no large prospective studies or randomized controlled trials demonstrating its efficacy in improving neurologic outcomes in ECMO patients. There is also a paucity of data regarding outcomes in older children or long-term ramifications of vascular reconstruction.
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Affiliation(s)
- Tiffany Zens
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ
| | - R Scott Eldredge
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ
| | - Manrit Gill
- University of Arizona College of Medicine, Phoenix, AZ
| | - Steven Mathew
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ
| | - Mark Molitor
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ
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Transcatheter management of life-threatening pulmonary arteriovenous fistula with extracorporeal membrane oxygenation support in an infant. Cardiol Young 2023; 33:498-501. [PMID: 36047509 DOI: 10.1017/s1047951122002724] [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] [Indexed: 11/06/2022]
Abstract
Pulmonary arteriovenous malformation is a rare disease leading to cyanosis, where there is a direct relation between the pulmonary artery and pulmonary vein without a capillary structure. Arteriovenous fistulae may be single or multiple. Clinical signs emerge depending on the size of the fistulae and amount of shunt. Due to the advancements in transcatheter devices and increased experience render enable the fistula embolisation procedure as an alternative to surgical treatment. Extracorporeal membrane oxygenation is used to support the patient haemodynamically and respirationally in cases of treatment-resistant, severe and revocable cardiac or pulmonary sufficiency. This paper presents an infant patient with pulmonary arteriovenous malformation, who had haemodynamic instability due to severe hypoxia and received successful transcatheter fistula embolisation via extracorporeal membrane oxygenation under emergency conditions.
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Characteristics of pediatric non-cardiac eCPR programs in United States and Canadian hospitals: A cross-sectional survey. J Pediatr Surg 2022; 57:892-895. [PMID: 35618493 DOI: 10.1016/j.jpedsurg.2022.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/20/2022] [Accepted: 04/27/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To characterize practices surrounding pediatric eCPR in the U.S. and Canada. METHODS Cross-sectional survey of U.S. and Canadian hospitals with non-cardiac eCPR programs. Variables included hospital and surgical group demographics, eCPR inclusion/exclusion criteria, cannulation approaches, and outcomes (survival to decannulation and survival to discharge). RESULTS Surveys were completed by 40 hospitals in the United States (37) and Canada (3) among an estimated 49 programs (82% response rate). Respondents tended to work in >200 bed free-standing children's hospitals (27, 68%). Pediatric general surgeons respond to activations in 32 (80%) cases, with a median group size of 7 (IQR 5,9.5); 8 (20%) responding institutions take in-house call and 63% have a formal back-up system for eCPR. Dedicated simulation programs were reported by 22 (55%) respondents. Annual eCPR activations average approximately 6/year; approximately 39% of patients survived to decannulation, with 35% surviving to discharge. Cannulations occurred in a variety of settings and were mostly done through the neck at the purview of cannulating surgeon/proceduralist. Exclusion criteria used by hospitals included pre-hospital arrest (21, 53%), COVID+ (5, 13%), prolonged CPR (18, 45%), lethal chromosomal anomalies (15, 38%) and terminal underlying disease (14, 35%). CONCLUSIONS While there are some similarities regarding inclusion/exclusion criteria, cannulation location and modality and follow-up in pediatric eCPR, these are not standard across multiple institutions. Survival to discharge after eCPR is modest but data on cost and long-term neurologic sequela are lacking. Codification of indications and surgical approaches may help clarify the utility and success of eCPR.
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Tierradentro-Garcia LO, Stern JA, Dennis R, Hwang M. Utility of Cerebral Microvascular Imaging in Infants Undergoing ECMO. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1827. [PMID: 36553271 PMCID: PMC9776869 DOI: 10.3390/children9121827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Infants who require extracorporeal membrane oxygenation (ECMO) therapy have an increased risk of neurological complications and mortality. Microvascular imaging (MVI) is an advanced Doppler technique that allows high-resolution visualization of microvasculature in the brain. We describe the feasibility and utility of MVI for the evaluation of cerebral microvascular perfusion in patients undergoing ECMO. METHODS We retrospectively analyzed brain MVI scans of neonates undergoing ECMO. Two pediatric radiologists qualitatively assessed MVI scans to determine the presence or absence of tortuosity, symmetry, heterogeneity, engorgement, and hypoperfusion of the basal ganglia-thalamus (BGT) region, as well as the presence or absence of white matter vascular engorgement and increased peri-gyral flow in the cortex. We tested the association between the presence of the aforementioned brain MVI features and clinical outcomes. RESULTS We included 30 patients, 14 of which were male (46.7%). The time of ECMO duration was 11.8 ± 6.9 days. The most prevalent microvascular finding in BGT was lenticulostriate vessel tortuosity (26/30, 86.7%), and the most common microvascular finding in the cortex was increased peri-gyral flow (10/24, 41.7%). Cortical white matter vascular engorgement was significantly associated with the presence of any poor outcome as defined by death, seizure, and/or cerebrovascular events on magnetic resonance imaging (p = 0.03). CONCLUSION MVI is a feasible modality to evaluate cerebral perfusion in infants undergoing ECMO. Additionally, evidence of white matter vascular engorgement after ECMO cannulation could serve as a predictor of poor outcomes in this population.
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Affiliation(s)
| | - Joseph A. Stern
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Rebecca Dennis
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Misun Hwang
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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