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Freeman JN, Giroux C, King T, Marbrey C, Maready M, Pasha S, Davis J. Variations in Management and Clinical Outcomes for Children With Diabetic Ketoacidosis in an Academic Pediatric Versus Community Emergency Department Setting. Pediatr Emerg Care 2024; 40:e133-e138. [PMID: 38563797 DOI: 10.1097/pec.0000000000003197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Our objectives were to characterize variations from standardized, evidence-based guidelines in the management of pediatric patients with diabetic ketoacidosis (DKA) based on initial presentation to a tertiary pediatric emergency department (PED) versus a community emergency department (OSH) and compare clinical outcomes. METHODS We conducted a retrospective study on children 18 years and younger with DKA who presented to an OSH or PED over a 3-year period. Treatments monitored for variation included intravenous fluid management, insulin delivery, and sodium bicarbonate administrations. Clinical outcomes included time to anion gap correction and on insulin infusion, hypokalemia, hypoglycemia, rapid serum glucose decline, cerebral edema, mechanical ventilation, mortality, and time from initial presentation to hospital discharge. RESULTS Children with DKA who presented to an OSH (n = 250) were more acidotic (pH 7.11 vs. 7.13, P = 0.001) and had larger anion gaps (28.8 vs. 25.5, P < 0.001) compared with children presenting to the PED (n = 237). The OSH patients were more likely to receive larger fluid boluses (>20 cc/kg or >1000 ml, 43% vs. 4%, P < 0.001), sodium bicarbonate (5% vs. 0%, P < 0.001), and intravenous bolus insulin (28% vs. 0%, P < 0.001). The OSH group were less likely to be started on maintenance intravenous fluids (70% vs. 99%, P < 0.001) or receive potassium in maintenance intravenous fluids (14% vs. 42%, P < 0.001). The OSH group had longer anion gap correction times (754 vs. 541 mins, P < 0.001), insulin infusion times (1018 vs. 854 min, P = 0.003), and times to hospital discharge (3358 vs. 3045 mins, P < 0.001). Incidence of hypokalemia, hypoglycemia, rapid glucose decline, cerebral edema, and deaths were similar between the 2 groups. CONCLUSIONS Our study demonstrated significant variations in the initial management of pediatric DKA patients by OSH facilities that deviated from an evidence-based treatment pathway utilized by a PED. Statewide quality improvement initiatives could help improve the overall clinical care provided to pediatric DKA patients.
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Affiliation(s)
| | - Callie Giroux
- Division of Pediatric Hospitalist, Department of Pediatrics
| | | | - Christina Marbrey
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | - Matthew Maready
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | - Simeen Pasha
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS
| | - Justin Davis
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
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Waddell K, Gaither SL, Rockwell N, Tofil NM, Rutledge C. The Impact of a Multifaceted Simulation Education and Feedback Program for Community Emergency Departments on Pediatric Diabetic Ketoacidosis Management. Pediatr Emerg Care 2023; 39:413-417. [PMID: 37163689 DOI: 10.1097/pec.0000000000002961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVES We sought to determine if general emergency departments (GEDs) were managing pediatric diabetic ketoacidosis (DKA) correctly and if management could be improved using a multilayered educational initiative. We hypothesized that a multifaceted program of in situ simulation education and formal feedback on actual patient management would improve community GED management of pediatric DKA. METHODS This study combined a prospective simulation-based performance evaluation and a retrospective chart review. A community outreach simulation education initiative was developed followed by a formal patient feedback process. RESULTS Fifteen hospitals participated in simulation sessions and the feedback process. All hospitals were scored for readiness to provide care for critically ill pediatric patients using the Emergency Medical Services for Children (EMSC) Pediatric Readiness Assessment. Six of the 15 have had a second hospital visit that included a DKA scenario with an average performance score of 60.3%. A total of 158 pediatric patients with DKA were included in the chart review. The GEDs with higher patient volumes provided best practice DKA management more often (63%) than those with lower patient volumes (40%). Participating in a DKA simulated scenario showed a trend toward improved care, with 47.2% before participation and 68.2% after participation ( P = 0.091). Participating in the formal feedback process improved best practice management provided to 68.6%. Best practice management was further improved to 70.3% if the GED participated in both a DKA simulation and the feedback process ( P = 0.04). CONCLUSIONS A multifaceted program of in situ simulation education and formal feedback on patient management can improve community GED management of pediatric patients with DKA.
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Affiliation(s)
- Kristen Waddell
- From the Pediatric Intensive Care Unit, Children's of Alabama, Birmingham, AL
| | - Stacy L Gaither
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Nicholas Rockwell
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Nancy M Tofil
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Chrystal Rutledge
- Division of Pediatric Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
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Alsaedi H, Lutfi R, Abu-Sultaneh S, Montgomery EE, Pearson KJ, Weinstein E, Whitfill T, Auerbach MA, Abulebda K. Improving the Quality of Clinical Care of Children with Diabetic Ketoacidosis in General Emergency Departments Following a Collaborative Improvement Program with an Academic Medical Center. J Pediatr 2022; 240:235-240.e1. [PMID: 34481806 DOI: 10.1016/j.jpeds.2021.08.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the impact of a collaborative initiative between a group of general emergency departments (EDs) and an academic medical center (AMC) on the process of care provided to patients with diabetic ketoacidosis (DKA) across these EDs. STUDY DESIGN A retrospective cohort study (January 2015 to December 2018) of all pediatric patients <18 years who presented with DKA to participating EDs and were subsequently admitted to the pediatric intensive care unit at the AMC. Our multifaceted intervention included simulation with postsimulation debriefing, targeted assessment reports, distribution of DKA best practices, pediatric DKA module, and scheduled check-in visits. The process of clinical care was measured by adherence to the pediatric DKA 9-item checklist. Adherence was scored based on the number of items performed correctly and calculated using equal weight for items and dividing by the total number of items. Patients' clinical outcomes also were collected. RESULTS A total of 85 patients with DKA were included in the analysis; 38 patients were in the preintervention, and 47 were in the postintervention. There was a statistically significant improvement in adherence to the DKA checklist from 77.8% to 88.9%. Two of the 9 checklist items (hourly glucose check and appropriate fluid rate) showed statistically significant improvement. No significant change in patient clinical outcomes was noted. CONCLUSIONS Our collaborative initiative resulted in significant improvements in adherence to pediatric DKA best practices across a group of general EDs. A collaborative approach between general EDs and AMCs is an effective improvement strategy for pediatric emergency care.
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Affiliation(s)
- Hani Alsaedi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Riad Lutfi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Samer Abu-Sultaneh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Erin E Montgomery
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Kellie J Pearson
- LifeLine Critical Care Transport, Indiana University Health, Indianapolis, IN
| | - Elizabeth Weinstein
- Division of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Travis Whitfill
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Marc A Auerbach
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Kamal Abulebda
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN.
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Abulebda K, Whitfill T, Montgomery EE, Kirby ML, Ahmed RA, Cooper DD, Nitu ME, Auerbach MA, Lutfi R, Abu-Sultaneh S. Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program. Pediatr Emerg Care 2021; 37:543-549. [PMID: 30870337 DOI: 10.1097/pec.0000000000001751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs. METHODS This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores. RESULTS A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline. CONCLUSIONS This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.
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Affiliation(s)
- Kamal Abulebda
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | | | | | | | - Rami A Ahmed
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Dylan D Cooper
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Mara E Nitu
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | | | - Riad Lutfi
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Samer Abu-Sultaneh
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
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Thawer Z, Gregoire K, Coo H, Saleh DS. Variability in Emergency Management of Pediatric Diabetic Ketoacidosis. Can J Diabetes 2021; 45:757-760. [PMID: 34112617 DOI: 10.1016/j.jcjd.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/27/2021] [Accepted: 03/09/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Our aim in this study was to identify pediatric patients presenting in diabetic ketoacidosis (DKA) who received initial treatment inconsistent with current guidelines, and then to track associated complications. METHODS This retrospective chart review examined 47 pediatric patients admitted to our institution with DKA, including those transferred from community hospitals. Primary outcome measures were exposure to treatment-related risk factors for cerebral edema (CE), including administration of an intravenous (IV) insulin bolus, IV bicarbonate, insulin within 1 hour of IV fluid start and non-NPO (nil per os) status. RESULTS Seventy-five percent of patients were exposed to at least one management practice that deviated from guidelines. Thirty-four percent of patients were exposed to a treatment-related risk factor for CE, with a significantly higher prevalence in those presenting to community centres (52% vs 19%; p=0.02). There were no radiologically confirmed cases of CE. CONCLUSIONS Despite the presence of multiple, evidence-based guidelines, a significant proportion of children---and especially those who present to community centres---are exposed to practices that increase CE risk.
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Affiliation(s)
- Zoyah Thawer
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada; Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
| | - Keith Gregoire
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Helen Coo
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
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Temporal patterns of hospitalizations for diabetic ketoacidosis in children and adolescents. PLoS One 2021; 16:e0245012. [PMID: 33411822 PMCID: PMC7790255 DOI: 10.1371/journal.pone.0245012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/19/2020] [Indexed: 12/17/2022] Open
Abstract
Objectives To examine the temporal patterns of hospitalizations with diabetic ketoacidosis (DKA) in the pediatric population and their associated fiscal impact. Methods The Texas Inpatient Public Use Data File was used to identify hospitalizations of state residents aged 1month-19 years with a primary diagnosis of DKA during 2005–2014. Temporal changes of population-adjusted hospitalization rates and hospitalization volumes were examined for the whole cohort and on stratified analyses of sociodemographic attributes. Changes in the aggregate and per-hospitalization charges were assessed overall and on stratified analyses. Results There were 24,072 DKA hospitalizations during the study period. The population-adjusted hospitalization rate for the whole cohort increased from 31.3 to 35.9 per 100,000 between 2005–2006 and 2013–2014. Hospitalization volume increased by 30.2% over the same period, driven mainly by males, ethnic minorities, those with Medicaid insurance and uninsured patients. The aggregate hospital charges increased from approximately $69 million to $130 million between 2005–2006 and 2013–2014, with 66% of the rise being due to increased per-hospitalization charges. Conclusions There was progressive rise in pediatric DKA hospitalizations over the last decade, with concurrent near-doubling of the associated fiscal footprint. Marked disparities were noted in the increasing hospitalization burden of DKA, born predominantly by racial and ethnic minorities, as well as by the underinsured and the uninsured. Further studies are needed to identify scalable preventive measures to achieve an equitable reduction of pediatric DKA events.
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Bhatt P, Dave M, Amponsah JK, Jain A, Yagnik P, Asare-Afriyie B, Donda K, Sharma M, Parmar N, Patel A, Bhatt N, Lunsford AJ, Dapaah-Siakwan F. Etiologies, trends, and predictors of 30-day pediatric readmissions after hospitalizations for diabetic ketoacidosis in the United States. Pediatr Diabetes 2020; 21:969-978. [PMID: 32469429 DOI: 10.1111/pedi.13059] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 05/22/2020] [Accepted: 05/23/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To determine the causes, predictors, and trends of 30-day readmissions following hospitalizations for pediatric diabetic ketoacidosis (DKA) in the United States (US) from 2010 to 2014. RESEARCH DESIGN AND METHODS We used International Classification of Diseases, ninth revision, Clinical Modification codes to identify children with DKA aged 2 to 18 years from the National Readmission Database in the US. Patients who had readmission within 30 days after an index admission for DKA were included in the study. We combined similar diagnoses into clinically important categories to determine the cause of readmission. The primary outcome was all-cause 30-day (AC30) readmissions. Categorical and continuous variables were analyzed using chi-square or student's t-test or Wilcoxon rank sum tests respectively. We performed multivariable logistic regression to identify predictors of 30-day readmission. RESULTS From 2010 through 2014, a weighted total of 87 815 index DKA-related pediatric hospitalizations were identified of which, 4055 patients (4.6%) had AC30 readmissions and this remained unchanged during the study period. Of all the readmissions, 69% were attributed to DKA. In multivariable regression analysis, the odds of AC30 readmission and 30-day readmission attributed to DKA alone were increased for females, adolescents, patients with depression and psychosis, and discharge against medical advice, while private insurance, the highest income quartile, and admission at teaching hospitals were associated with lower odds of AC30 readmission and 30-day readmission attributed to DKA only. CONCLUSION We identified several factors associated with readmission after hospitalization for DKA. Addressing these factors such as depression may help lower readmissions after an admission for DKA.
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Affiliation(s)
- Parth Bhatt
- Department of Pediatrics, United Hospital Center, Bridgeport, West Virginia
| | - Mihir Dave
- Department of Internal Medicine, University of Nevada, Reno, Nevada
| | - Jason K Amponsah
- Department of Public Health, Emory School of Public Health, Atlanta, Georgia
| | - Apurva Jain
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, Texas
| | - Priyank Yagnik
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas
| | - Barbara Asare-Afriyie
- Department of Public Health, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Keyur Donda
- Department of Pediatrics, University South Florida, Tampa, Florida
| | - Mayank Sharma
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Narendrasinh Parmar
- Department of Pediatrics, Brookdale University Hospital Medical Center, Brooklyn, New York
| | - Achint Patel
- Department of Internal Medicine, University of Nevada, Reno, Nevada
| | - Neel Bhatt
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Alison J Lunsford
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, Texas
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Lawrence SE. The Use of Clinical Pathways and Order Sets in the Management of Diabetic Ketoacidosis. Can J Diabetes 2019; 43:295-296. [DOI: 10.1016/j.jcjd.2019.05.009] [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: 10/26/2022]
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Evans JM, Dayal P, Hallam DL, Natale JE, Kodali P, Sauers-Ford HS, Marcin JP. Illness Severity of Children Admitted to the PICU From Referring Emergency Departments. Hosp Pediatr 2018; 8:404-409. [PMID: 29858424 DOI: 10.1542/hpeds.2017-0201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To compare patient factors and outcomes among children admitted to PICUs from referring versus children's hospital emergency departments (EDs). METHODS Pediatric patients (<19 years old) admitted to PICUs from referring and children's hospital EDs from July 1, 2011 to June 30, 2013. We compared demographic and clinical factors, including severity of illness as measured by a recalibrated Pediatric Index of Mortality, version 2 score. RESULTS Of 80 045 children from 109 PICUs, 35.6% were admitted from referring EDs and 64.4% were admitted from children's hospital EDs. Children from referring EDs had higher illness severity (Pediatric Index of Mortality, version 2-predicted risk of mortality, 3.1% vs 2.2%, P < .001), were more likely to be mechanically ventilated within their first hour in the PICU (28.4% vs 23.4%, P < .001), and had higher observed mortality (3.3% vs 2.1%, P < .001). Once adjusted for illness severity and other confounders in a multivariable logistic regression model, there was no difference in the odds of mortality between children from referring and children's hospital EDs (odds ratio: 0.90; 95% confidence interval: 0.79 to 1.02, P = .09) CONCLUSIONS: Children transferred to PICUs from referring EDs had higher illness severity on arrival compared with children admitted from children's hospital EDs. Variations in patient selection for transfer or pretransfer treatment at referring EDs may contribute to the greater illness severity of transferred children. Referring hospitals may benefit from leveraging existing resources to improve patient stabilization before transfer.
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Affiliation(s)
- Jacqueline M Evans
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - Parul Dayal
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - Douglas L Hallam
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - JoAnne E Natale
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - Pranav Kodali
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - Hadley S Sauers-Ford
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - James P Marcin
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
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