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Ord
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2o13
Ord
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thro
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orld
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toth
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otio
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pati
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diag
nose
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ithN
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hods
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udy
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year
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ere
incl
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inth
est
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ail-
base
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and
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ons
rega
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iagn
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wer
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aile
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pati
ents
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ere
give
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mer
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valu
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dica
ting
wor
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valid
resp
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led
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tion
nair
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imal
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cton
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oas
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rall,
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een
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pre-
diag
nosi
sto
post
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gnos
is,
mor
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tslim
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sun
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ngpe
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vs.
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vs.
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n-P
rote
ctiv
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ehav
iors
Bef
ore
and
Aft
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iagn
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wit
hN
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go
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ore
men
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ort
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da9
r1en
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prio
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diag
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ithNP
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ared
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omen
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ere
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omen
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crea
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ilysu
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sis
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vs.
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).
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lyS
un
scre
enU
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efore
and
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erD
iag
no
sis
wit
hN
MS
C
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enal
sore
port
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&W
eiir
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hing
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WN
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pare
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en(4
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%),
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sre
port
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sed
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tive
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Sun
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tect
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Clo
thin
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efor
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fter
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44_________—
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r
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ns
__
__
__
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iagn
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ter
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ctof
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enth
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en,
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chis
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enby
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erns
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tap
pear
ance
.-
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gnos
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ithN
MSC
resu
ltsIn
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tive
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av
iors
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cludin
gin
cre
ase
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reen
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ease
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ecti
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ore
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otio
nal
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ctan
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gnosi
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ithN
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ey
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eren
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otio
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ric
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dvan
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sof
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epre
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ngul
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ct.
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hick
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sal
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dram
atic
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icat
ions
for
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succ
ess
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pas
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lace
men
tof
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tan
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hen
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mar
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roug
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date
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spe
dorm
ned
toquan
ti’
how
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thic
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ters
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aps
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ta
pivo
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t
Stu
dyA
ims
_____
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atsq
uare
22x
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artif
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licon
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inm
odel
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ere
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ted
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ate
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ess.
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lutio
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Inc.
).•
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caliz
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ied
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ndom
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kled
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esu
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ong
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efl
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oto
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tby
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ach
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inci
sed,
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inty
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lfa
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ing
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ages
wer
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aslo
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aced
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it
Can
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OW
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e1.‘
Lim
itat
ions
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iflc
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uesu
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s•
Inte
r-fl
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Ref
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ces
1.Zi
telli
JA.T
hebi
bbed
flap
For
nasa
lra
cons
tiuct
ion.
Arc
hD
ennat
ol
1989
:125
:957
—9.
2.C
ook
JL.
Rec
onst
ruct
ive
utili
tyof
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blob
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p:le
sson
sfr
omts
psu
cces
ses
and
failu
res.
Den
nato
lS
urg2
005;
31(B
Pt
2):1
024—
33.
3.M
tler
C.).
Des
ign
prin
cipl
esfo
rtr
ansp
ositi
onfl
aps:
Ihe
rhom
bic
(sin
gle-
lobe
d).
bfob
ed,
and
trilo
bed
flap
s.D
um
sato
ISu
rg.
2014
:40:
43-5
24.
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eM
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per
D.
Pivo
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int
and
seco
ndar
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fect
prob
lem
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ithro
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ign
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nim
izab
onol
Ala
rD
ispl
acem
ent.
Oem
aMsw
g,
2000
:26(
4):
354-
362
6.C
hoM
.K
im0.
Mod
ifica
tion
ofth
eZi
telhi
Bib
bed
Flap
:a
com
pari
son
offla
pdy
nars
iica
inhu
man
cada
vers
.A
rch
Fec
Pie
s)Su
ig.
2000
:8:4
04-4
09
An
aly
sis
ofth
eef
fect
sof
gra
ded
skin
thic
kn
ess
onm
echan
ical
stra
inof
the
bib
bed
tran
sposi
tion
flap
Pau
lJ
Gru
ber
MD
,S
ana
Sye
dB
S,
Eth
anM
cCla
inB
S,E
ric
Arm
bre
cht
PhD
,Ia
nA
Mah
erM
DS
aint
Lou
isU
nive
rsit
yD
epar
tmen
tof
Der
mat
olog
y
Res
ult
sI
Co
ncl
usi
on
s
*1
•M
ean
over
alst
rain
thae
ased
both
qual
itativ
ely
and
quan
titat
ivel
yba
sed
onsk
inth
ickn
ess
•M
axst
rain
was
alw
ays
loca
ted
near
tert
iary
defe
ctan
dpr
ogre
ssed
ina
linea
rfa
shio
nal
ong
the
flap
pedi
de•
Qua
litat
ivel
y,it
appe
ars
asth
ough
min
imum
stra
in(c
ente
rof
rota
tion)
mig
rate
ssu
peri
ody
upth
efla
ppe
dide
asm
odel
thic
knes
sin
crea
sed.
•To
eval
uate
the
efle
cta
ofgr
aded
nasa
lsk
inth
ickn
ess
onpe
dide
stra
inofl
bibb
edtr
ansp
ositi
onfl
aps
inor
der
tohe
lpgu
ide
lap
desi
gnpr
inci
ples
and
optim
ize
surg
ical
outc
anes
.
Rec
om
men
dat
ion
s
Mr.
nst
ain
fri
ski,,
Viir
kner
Mod
elM
arr
an
sV
nine
Mie
nof
Bar
ked
ike
——
.as
nS
n
SnI
a-—CA
Ca
—
:I
‘I
iar:
I..:,
;,.:
‘;;:
,,.:
r1m
m3m
m4am
SO
C
•R
otat
iona
lce
nter
ofth
ebi
bbed
fap
disp
lace
sal
ong
the
axis
otpe
dtde
base
don
skin
thic
knes
s•
Thi
sst
ud
ysu
pport
sth
eco
nce
pt
that
over
sizi
ng
offl
aps
may
behe
lpfu
lin
area
sof
thic
kse
baceo
us
tiss
uein
orde
rto
care
d(o
rpi
vota
lre
stra
int
I
pedl
obe
inth
ehig
h-c
onti
ast
spec
kle
dp
atte
rnof
dots
.D
igita
lim
age
corr
elat
ion
was
used
toac
cura
tely
dete
rmin
eth
ehi
ll-fe
iddi
spla
cem
ent
and
two-
dim
ensi
onal
stra
inof
the
dotte
dgi
stal
ong
hefla
ppo
did
e.
S
__
___
Bac
kgro
un
dA
nten
alat
cet
lico
ster
oid
,(A
NC
S)ad
min
iste
red
for
risk
ofpr
eter
mde
tiver
yde
crea
se
mot
hidt
tyof
prem
atu
tity
ifpr
eter
mbi
rth
occu
rs(1
.7).
Alt
houg
hea
rty
antm
alit
tadi
esbond
that
man
ydo
ses
led
togr
owth
rest
rict
ion
(8-t
o),
asi
ngle
repea
tdo
sew
asfo
und
tobe
nefi
t
hum
anne
onat
esw
itho
uta
sig
nJc
ant
dem
eate
inbi
rth
wei
ght
(4,
73.
Cur
rent
giad
etin
esre
com
men
dtw
odo
ses
ofA
NC
Sad
min
icte
red
24ho
urs
apar
tat
asi
ngle
cou
rse’
Are
pea
tcoune
isad
min
iste
red
82
wee
ksla
ter
ifth
em
othe
rre
mai
nsat
rtik
of
pret
erm
detw
ety.
How
ever
,th
em
ain
stud
tes
supp
orti
nga
repea
tco
urse
excl
uded
wam
en
wit
hpr
etet
mpr
emat
ure
rntp
lure
oIn
wm
bran
esfP
PR
0Mf
(1-5
),be
caus
eof
ath
eore
tica
tri
skof
chsn
oans
nios
;tis
din
toth
eim
mun
osup
pies
sast
effe
cts
ofgtu
coco
rstc
otd
s.A
sa
‘rit
a!,,
ther
eis
insu
ffic
ient
data
tore
conw
send
are
peat
dose
ofM
Ica
inw
omen
w;t
h
FIR
OM
.
Tw
ost
udie
sIn
clud
ew
omen
with
PPR
OM
(6—
1)an
ddi
dno
tfi
ndan
incr
ease
din
cide
nce
ofch
oeio
amni
onis
isw
ith
are
peat
cose
te,
alth
ough
wom
enw
ith
PPR
OM
wer
eno
tan
atya
ed
sepa
rate
lyA
tSS
MSt
.M
ary’
s,m
ost
MFM
sad
min
iste
rre
pea
tA
NC
Sfo
rPP
RO
M,
and
this
isno
tas
soci
ated
wit
hin
crea
sed
chor
ioam
nlon
itis
.Th
iskn
swte
dge
gap
crea
tes
an
oppo
rtun
ity
for
stud
yof
repe
atdo
ses
ofA
NC
Iin
clud
ing
only
wom
enw
ith
PR
OM
.
Res
earc
hQ
ues
tio
ns
__
__
Stu
dyD
esig
nT
his
isan
inve
stig
ator
-mut
ated
retr
ospe
ctiv
eco
tton
stud
ycf
wo
men
seth
PPR
OM
who
wet
eei
ther
expo
sed
tore
peat
Mid
orno
t;th
eco
ndit
ions
bein
gem
min
edaf
ter
this
eapo
sure
are
(1)
neon
atal
moe
tidi
tyan
dm
orta
lity
and
(2)
choit
onnis
nit
isto
achi
eve
ob
ject
ives
(s)
and
(2)
rmpe
ctty
efy
Incl
usio
ncr
iter
ia;
•P
rete
rmpr
emat
ure
rupt
ure
ofm
emb
ran
esc
34co
mpl
eted
wee
ks
•R
ecur
rent
orco
ntin
ued
thre
atof
pret
erm
deli
very
wit
hin
the
7da
ysaf
ter
enro
llm
ent
•In
itia
ted
Ito
tco
urse
ofA
Nd
14or
mor
eda
ysbe
fore
enro
llm
ent
and
befo
re52
com
plet
edw
eeks
Eec
lusi
oncr
iter
ia,
•A
ctiv
ecl
inic
alch
orio
amni
onit
is
•G
esta
tios
alag
ele
ssth
an23
com
plet
edw
eeks
alti
me
ofPP
RO
M
•G
esta
tios
alag
egre
ater
than
34w
eeks
gest
alio
nal
age
Asa
mpl
esi
zeof
100
wom
enin
cac
tsgr
oup
was
calc
ulat
edas
anea
erci
se,
bai
rdon
a
pow
erof
0.8,
alph
aof
00
5,
and
inci
denc
eof
com
poss
teneo
nat
aIm
orbi
dity
(res
pira
tory
dist
ress
synd
rom
e,nea
otu
ing
ente
rtco
litr
s,gr
ades
Illan
dIV
tntr
aven
tr,c
ular
Isen
sore
hage
,an
dde
ath)
of63
.6%
inth
epl
aceb
oam
,an
d43
.9%
‘irath
e
trea
tmen
tar
mof
ani
mla
dyde
sign
edst
udy
ml
wanen
wit
hIn
tact
mm
otha
nen
(Cat
tle
etat
,ci
ted
abov
e).
0P
rim
ary
outc
ome;
com
posi
teof
neon
atal
resp
irat
ory
HO
dis
tres
ssy
ndro
me,
necr
otiz
ing
ente
eoco
!iti
n,
grad
esIll
aasd
IVm
ntra
vent
hoat
arhe
nson
hage
,H
and
deat
h,,,.
FH
0—
Res
ults
Into
tal.
187
wom
enan
d21
6n
eon
ates
wer
ein
clud
ed.
77
wo
men
tece
iyed
stan
dar
dof
care
and
105
rece
iyed
repea
tA
NC
S.T
here
wer
e28
com
ple
tetw
inse
tsan
d4
inco
mpl
ele
Pei
nsin
duded
inth
e
anal
ysis
for
ato
tal
of32
twin
pre
gnan
cies
.M
ater
nal
age,
den
sog
rap
hie
t,p
anty
,body
mas
tin
dex,
and
med
ian
get
tati
on
alag
eat
ruptu
rean
dat
deli
very
Wer
eco
mpar
able
bet
wee
ngro
ups.
Bat
elin
e
dif
fere
rwm
innat
errs
a(ch
arac
teri
stic
san
dde
live
rych
arac
teri
stic
wer
ed
eter
min
edus
ing
chi-
squar
ete
es,
for
cate
gori
cal
var
iab
les
and
Man
n-W
bit
ney
’W,t
ccto
nte
nt
for
conti
nuous
var
iab
tet.
The
prim
ary
outc
om
eof
com
posi
teneo
nat
alm
orb
idit
y/m
ort
alit
yw
asd
eter
min
edus
ing
alo
gist
ic
regr
essi
on,
cont
roll
ing
for
ges
tatt
onal
age
atde
hvei
yan
dra
ce.
ITab
le1:
Bas
elin
ean
dD
eliv
ery
Char
acte
rist
icIV
arta
bles
—,p
5!7
No
Rep
eal
I
Enr
olle
dm
othe
rs77
.10
5
Fet
uses
/new
born
s97
t19
Mat
erna
lag
eft
).m
ean
tstd
26.4
±6.
021st
6.5
.39
Mat
erna
)B
MI,
mea
n±s
td30
.6±
1.5
32.6
±9.
3.2
0
Pari
ty,
nf%
)29
0.
flj)
35(3
3.3)
11
!J)
23(2
1.9)
—l
47(4
4.8)
His
tory
ofpr
eter
mde
live
ry!P
if)[
25(2
3.6)
.87
cth
nid
ty,n
(%)
,-
.90
Afr
ican
Am
eric
an32
Cau
casi
an-
42(5
5.3)
56(5
4.4)
Oth
er-
......
..1J1
4(3
-9)
Mat
erna
lC
BS,
n(1
€).
1316.1
)2
11
0.5
)-
so
Smok
er.
n(9
;)19(2
47)
30(1
8.6)
68
twin
pre
gn
ancy
1,p
.jj
22jL
N1
8(1
71
).1
0
yp
ort
ofto
coly
szs.
n(“
I-
PJ1
iL...L
.94
(79.
0).5
1‘A
nt,
tioti
cre
port
ed.4
J[95
99.0
)81
2(94
.1)
.53
Ges
tati
onal
age
(wit)
atde
live
ry,
mea
n±
std
358±
2.0
31-3
!2.
9.1
7
--
16756±
4167)
16
75
±6
05
.3:
-Ia
Rea
son
for
d&.iv
ery,
nt%
J
)la
bor
not
stop
ped
39)4
0.2)
49)4
1.2)
rlan
ned/
nche
da!e
d49
(50
5)59
(49.
6).3
9C
hoei
oam
nion
itzs
4(4
I3
(2.5
)A
bnor
mal
feta
lta
acin
,g_,
,,,,
,,,_j
Jjfl
,8
16.7)
.72
PIH
,Lfl_
_0
NC
Rou
teotd
eI;
very
.,4j)
,.3
2
Ces
area
n47
(49.
0)49
41.2
)‘
Vag
inal
70(5
8.8)
Clin
ical
chor
ioam
nion
itis
.n
(%(
27(2
5.7)
.14
His
topa
thol
ogic
chor
ioam
nmon
itis,
n(%
)48
.82
Cor
dpH
arte
rial
,m
ean
fstd
7.3
±0
57.
3±al
.74
Cor
dpH
veno
us,
mea
n±
std
7.3
±0.
57,
3±
111
.63
Apg
ar1
mm<
s,n
(%)
21(2
3.7)
38(3
2.8)
.67
Apg
arS
mmc
7,n
(%),,
,25
(21.
6).4
5
Rep
eat
AN
CS
was
asso
ciat
edw
ith
dec
reas
edre
spir
atory
mor
bidi
ty(P
c.0S
).N
eona
tal
hypo
gfyc
emia
and
clin
ical
aod
hist
olog
icch
otto
amni
onit
isw
ere
sim
ilar
bet
wee
ngro
ups
(PrO
S,
.14,
.82
resp
ecti
vely
).W
hen
neo
nat
esunder
28w
eeks
wer
ean
a)yz
edle
par
ate)
y,
resp
irat
ory
mor
bidi
ty
rem
ained
the
only
outc
om
eat
the
leve
lof
sIgn
ific
ance
P—.0
5(.
Als
houg
hth
epa
irw
ise
com
pari
son
ol
com
posi
teneo
nat
alm
orbi
d;ty
bet
wee
nw
om
enw
hore
ceiv
eda
resc
ue
dose
ofA
dsan
dw
om
enw
ho
dud
not
wan
nign
:fsc
ant
this
wan
not
the
case
whe
nco
ntro
llin
gfo
rges
tati
onal
age
atde
live
ryan
d
race
. Tab
le2:
Neo
nata
lM
othi
d.ty
and
Mor
tat;
tyA
djus
ted
for
Cen
tatt
onal
Age
asD
eliv
ery
Var
iabl
esR
epea
tn/
N(%
)N
oR
epea
tn
/N
(%
)P
Com
posi
tem
orbi
disy
39/9
7(4
0.2)
63
/11
9(5
2.9
)—
t-
.02
:Resp
int
com
posi
te36/9
7(3
71)
61
/11
9(5
1.3
)‘
.05
tnlr
aven
lric
ula
rhem
orr
hag
e6/9
1(6
2)
8/1
19
(5.7
)1.
0
Nec
roti
zing
ente
roco
liti
s0/9
75
/11
9(4
,2)
NC
Hyp
ogly
cem
ia[
1419
7(1
44)
7/1
19(5
9)
.o6J
Neo
nata
ld
eath
I0/9
71/1
19(0
8)
Lim
itat
ions
I.S
tudy
desi
gna.
Req
uire
d14
day
late
ncy.
bat
usua
llyw
omen
who
deli
vere
dat
24da
yndi
dn’t
get
repe
atM
40,
whi
chis
clin
ical
lyun
surp
risi
ng,
but
affe
ctth
eda
tapr
ior
tosu
bgro
upan
afys
is(g
esta
lion
alag
eat
deli
very
Issi
gnif
ican
tlygr
eate
rin
the
repea
tA
RC
Sgr
oup)
b.R
etro
spec
tive
desi
gnad
mit
sor
sele
ctio
nbi
asdu
eto
co
nv
eeie
nce
nam
p5
ng
2.S
ampl
esi
rew
asno
tpo
wer
ful
enou
ghto
dete
cta
diff
eren
cem
neo
nata
lm
oet
alit
yC
rse
rious
mat
erna
lm
orbi
dity
.
3.T
heda
tase
tut
iliz
edfo
eth
isan
alys
isco
ntai
nstw
inu
and
ning
leto
nn.
seth
the
na;
on
tysi
ngle
ton.
iwin
sw
ere
coen
pare
das
indi
vidu
alsu
bjec
ts,
but
the
assu
mpt
ion
that
obse
rvat
ions
are
inde
pend
ent
and
not
rela
ted
isvi
olat
edto
tens
ede
gree
,as
win
sar
eno
tco
mplr
tey
inde
pend
eol.
The
reis
som
eli
tera
ture
that
sugg
ests
that
ifth
em
ajor
ity
ofca
ves
are
ind
epen
den
t,on
eo
n
perf
orm
stan
dard
stat
ittt
cal
test
sth
atas
sum
ein
depe
nden
ce-
How
ever
,th
ere
isot
her
lite
ratu
reth
atsu
gees
tsth
atm
odel
usu
chan
gen
enli
aed
esti
mat
ing
equa
tion
s(G
EE)
and
gene
rali
zed
line
arm
ired
mod
els
(01M
M)
shou
ldbe
utili
ged
toac
coun
tfo
rth
ela
ckof
inde
pend
ence
.T
his
anal
ysts
assu
med
inde
pend
ence
.
Co
ncl
usi
on
The
asso
ciat
ion
betw
een
com
posi
lene
onat
alm
orbi
dity
/mor
tali
tyan
dA
Nd
adm
inis
trat
ion
in
PPR
OM
isa
func
tion
ofge
stat
iona
lag
eat
deli
very
than
whe
ther
orn
ora
resc
ue
dose
ofA
CSw
asre
ceie
ed.
Rep
eal
AR
CS
isas
soci
ated
wit
ha
decr
ease
din
cade
nre
ofco
mpo
site
neon
atal
mot
bidi
fyan
dis
not
asso
ciat
edw
ith
ewre
ased
eate
nof
chor
ioam
rion
;tis
,F
urth
erpr
ospe
ctiv
est
udie
sar
ene
eded
Fut
ure
Res
earc
h
Mat
ched
retr
osp
ecti
ve
coho
etst
udie
sto
proh
ibit
ges
tati
onal
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skin
dis
ease
cause
dby
ade
laye
dty
peIV
hyper
sensi
tivit
yre
sponse
.N
umer
ous
stud
ies
have
impl
icat
edT
h17
cell
s,IL
-17,
and
IL-2
3in
the
pat
ho
gen
esis
ofce
rtai
nau
toim
mun
ean
dal
lerg
icdis
ease
sin
clud
ing
psor
iasi
san
dac
ute
AC
O.
IL-1
7de
fici
ent
mic
eha
vede
mon
stra
ted
redu
ced
cont
act
hype
rsen
siti
vity
resp
onse
sto
alle
rgen
san
dth
ere
has
been
incr
ease
dde
tect
ion
ofIL
-17
mR
NA
inac
ute
AC
Dbi
opsi
es.
•D
rugs
that
inhi
bit
11-1
7an
dIL
-23
have
been
succ
essf
ulin
trea
ting
psor
iasi
s,bu
tha
veno
tbe
enef
fect
ive
for
chro
nic
AG
O.
•T
hus,
the
impo
rtan
ceof
IL-I
lan
dIL
-23
inch
roni
cA
CO
rem
ains
undea
r.
We
iden
tifi
ed39
pati
ents
with
52bi
opsi
es(4
1/52
biop
sies
anal
yzed
)S
pong
iosi
sw
itheo
sino
phil
sw
asth
epr
edom
inan
thi
stol
ogic
patt
ern
(46%
),fo
llow
edby
supe
rfic
ial/
deep
ped
vas
cula
rin
filtr
ate
(17%
),sp
ongi
osis
(12%
),ps
ohas
ifor
m(8
%),
vacu
olar
inte
rfac
ede
rrna
liti
s(6
%),
and
othe
r(1
1%)
Norm
alsk
inco
ntr
ols
:IL
-Il
IL-1
7an
dIL
-23
stai
ned
adne
xal
stru
ctur
es,
low
er>
uppe
rep
ider
mis
,an
dm
ildsu
perf
icia
lpe
riva
scul
arin
filtr
ate
(10-
25%
ofly
rnph
sst
aine
d)
IL-2
3
11-1
7an
dIL
-23
expr
essi
onin
chro
nic
AC
Dis
uniq
ueco
mpa
red
tono
rmal
skin
and
psor
iasi
s.•
Thi
sm
ayex
plai
nw
hy11
-12/
23in
hibi
tors
have
had
limite
dsu
cces
sin
trea
ting
chro
nic
AC
D.
•T
helo
cati
onof
cyto
kine
expr
essi
onse
ems
tobe
impo
rtan
t.
Obje
ctiv
es•
We
soug
htto
iden
tify
the
imm
unoh
isto
chem
ical
(IH
C)
expr
essi
onof
lL-1
7an
dIL
-23
inch
roni
cA
CD
biop
sies
com
pare
dto
psor
iasi
san
dno
rmal
skin
cont
rols
.B
ybe
tter
unde
rsta
ndin
gth
ero
leof
IL-1
7an
dIL
-23
inch
roni
cA
CD
,w
em
aybe
able
tohe
lpgu
ide
futu
reth
erap
euti
cta
rget
s.
IL-1
7ex
pres
sion
inch
roni
cA
CD
with
psor
iasi
form
hist
olog
yis
iden
tica
lto
psor
iasi
sco
ntro
ls.
-T
hus,
lL-1
7in
hibi
tors
coul
dbe
help
ful
for
chro
nic
AC
Dw
ithps
oria
sifo
rmhi
stol
ogy
whe
not
her
opti
ons
Lim
itat
ions
lL-1
7
have
faile
d.
Pso
rias
isco
ntr
ols
:IL
-17
had
min
imal
tono
epid
erm
alst
aini
ng.
lL-2
3st
aine
dal
lof
epid
erm
is,
&bo
thst
aine
dpa
pilla
ryde
mia
lin
riltr
ate
(50-
75%
ofly
mph
sst
aine
d)
Met
ho
ds
Chro
nic
AC
Dbio
psi
es:
•S
ingl
ece
nte
rst
udy
(SL
UD
epar
tmen
tof
Der
mat
olog
y)S
mal
lsa
mpl
esi
ze(3
9pa
tien
ts.
52bi
opsi
es)
Sub
ject
ive
inte
rpre
tati
onof
biop
syst
aini
ng•
Poo
rst
aini
ngof
som
esp
ecim
ens
(wer
eex
clud
ed)
IL-I
?
lL-1
7an
dlL
-23
stai
ned
all
leve
lsof
the
epid
erm
isan
dde
rmal
peñv
ascu
lar
infi
ltrat
e(2
5-50
%of
Iym
phs
stai
ned)
•T
his
stud
yw
asap
prov
edby
the
SLU
IRB
inFa
ll20
17U
sing
CP
Tco
des
(950
44an
d88
305)
,w
eob
tain
eda
list
ofpa
tien
tsfr
om20
07-2
011
who
had
apr
ior
biop
sype
rfor
med
forA
CD
and
prev
ious
posi
tive
patc
hte
stin
g.•
Con
trol
sw
ere
obta
ined
byse
arch
ing
our
derm
atop
atho
logy
dat
abas
efo
r10
pso
has
isbi
opsi
es(p
osit
ive
cont
rols
)an
d10
beni
gnne
vus
exci
sion
sti
ps(n
egat
ive
cont
rols
).11
-17
and
IL-2
3im
mun
ohis
toch
emic
alst
aini
ngw
aspe
rfor
med
onal
lsp
ecim
ens
whi
chw
ere
then
anal
yzed
tode
term
ine
the
patt
ern
ofex
pres
sion
inch
roni
cAC
flco
mpa
red
toco
ntro
ls.
Ch
ron
icA
CD
bio
psi
esw
ith
pso
rias
iform
his
tolo
gy:
The
se3
biop
sies
had
abse
nce
ofIL
-17
stai
ning
,w
hich
mat
ched
the
stai
ning
patt
emin
psor
iasi
sco
ntro
ls
IL-2
3IL
-17
.
•11’
v1.
INTRODUCTION
SkincancersarethemostcommonlydiagnosedcancerintheUnitedStatesandthelifelongincidenceofapatientdevelopingskincancershasbeenincreasing.1in1500childrenhadalifetimeriskofdevelopingmelanomain1935comparedwithchildrenborntodaywhofacea1in33lifetimerisk.UVlighthasbeenconsideredtheprincipalknownandpreventablecarcinogeninthedevelopmentofskincancer.Tothisend!numerousprogramshavebeendevelopedtoeducatepatientsaboutthehazardsofsunexposureandcreatepoliciesforsunprotection.Nevertheless,moststatesrequireadoctor’snotetoallowstudentstousesunscreeninpublicschoolsandeventhen,thesunscreenhastobeappliedinthenurse’sofficeasitisconsideredmedication.PediatricskinisuniquelysusceptibletoINlightanditisimportantthatcaretakersareeducatedanthechallengesassociatedwithpediatricsunprotection.Intoddlersandschool-agechildren,currentAADrecommendationsincludeapplyingbroad-spectrumSPF30every2hourswhensunexposedandevenmorefrequentlywhenswimmingorsweating.Itisdifficulttogauge,however,howfrequentlycarecenters10110wtheserecommendations.ThereiscurrentlynofederalguidelineregulatinguseofsunscreenorothersunprotectivebehaviorsInU.S.childcarecenters.
OBJECTIVE
METHODS
Across-sectionalsurveywasofferedtostate-leveldirectorsofchild-carelicensingandtorandomlyselectedMissourichildcarecenters.
RESULTS
19surveyswerecollectedfromslate-leveldirectorsofchildcarelicensingwhichrepresentsa38%responserate(t9)5Oslates).68%ofrespondingstatesreportthattheirstatehasawrittenpokcyaddressingsunprotectioninchildcarecenters.All13policiesaddresssunscreenuse,withfewerpoliciesaddressinguseofsunprotectiveclothingoroutdoorplaytimeduringpeaksunhours(i.e.betweenlOam-2pm).Stateswithwrittensunprotectionpoliciesinplaceestimatehighernumbersofindividualcarecentersintheirslatesadopttheirownpoliciesaboutsunprotectioncomparedtothosestateswithoutwrittenpolicies.WhenaskedIfthereshouldbeafederalpolicyforsunprotectioninchildcarecenters.47%ofrespondingstate-leveldirectorssaid‘yeCand42%ofrespondingstate-leveldirectorssaid“no’.
Ofthe40randomlysurveyedMissourichildcarecenters,70%havewrittenpoliciesaboutsunprotection.Similartothestate-leveldata,allpoliciesaddresssunscreenusewithfewerpoliciesaddressinguseofsunprotectiveclothingoroutdoorplaytimeduringpeaksunhours.90%ofsurveyedcarecentersallowparentstoprovidesunscreenfromhome.Alsosimilartothestate-leveldata,whenaskedifthereshouldbeafederalpolicyforsunprotectioninchildcarecenters,53%saId“yes”and47%said“no”.
--
-4- -
-
DISCUSSION
—-.—- --
Ourstudyfoundthatthemajorityofrespondingstate-leveldirectorsofchildcarelicensingandMOchildcarecentershavesun-protectionpoliciesInplace,Natsurprisingly,sunscreeniscommonlyaddressedinpolicies.Thisislikelybecausesunscreenismorecommonlythoughtofandhasbeenaleadingeducationaltargetinavoidingskincancer.Thefindingsthatsunprotectiveclothingandsunavoidanceduringpeakhoursarelessemphasizedinpolicieshighlighttheneedforeducation.Althoughparentsplayarole,childcarecentersarealsoinfluentialInestablishinghealthysunprotectionhabits.IthasyettobedeterminedIfwrittenpoliciesonthestateorfederallevelshouldfillthisgap.ThisishighlightedinoursplitresponsetothequestionsoftheneedforafederalguidelineaddressingsunprotectioninchildcarecentersandlikelyreflectsthedifferencesofsomefavoringIndividualhealthautonomyversusotherswantinggovernmentcontroltoreduceratesofskincancer.
REFERENCES
Julia,E.P,1lro,A.M&Tbomn,l.A.(2015).PediatricemacretsandsunsafelyguidelineLCliJlicaiPediafrics,54fl2),1133-1140.Yan,A.c..&Cajielo-Soeclo,L.(2016).Oplinicinginnprotectionforchiidnt:Havingowdayintheann,JAMAPediatric,,170(4),318-319.EvetenJones5,GuyOPSw,SafetyPnclicesAsnongSchoolsintheUnitedStates.JAMADennatol.2017;153(5):39l.397.doi:IO.lOOl/j.madentatol.2Ol6.6274Reddy,5.(2017,May15).viherekidsaren’tallowedtoputonsumctsen:Inschool;teachingaboutannprotectionmae,intorosdblocbbecauseaunacItenisconsidemdmedicine;somestate,,superheroesandaUpesytOplikesstand.WallSinesJournal(Online)
4RESULTS
Flu,.1.Respondingstalesthathaveadaptedwntenpoliciesaboutsunprotecton.
ToascertainratesofsunprotectivepoliciesandtobetterdescribesunprotectivebehaviorsamongU.S.childcarecenters
IOutd,orpI.ypea‘a,bean
I—
HillOthercreel’s
FIgure2.StateswithwrittensunprotectionpoliciesreportwhattheirpoNd..specificallyaddress.
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pati
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all/
mos
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e
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ays
asse
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siet
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Enr
oll
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/der
mal
olog
lcal
surv
eIll
ance
Inte
rnis
ts’
vs.
Gas
troen
tero
logis
ts’
Pra
ctic
ean
dP
erce
pti
on
ofR
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D-R
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ain
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ance
SA
INT
LO
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Muham
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ami
MD
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kP
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D,
Reb
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Tal
kin
85,
Kat
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chro
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MD
SA
INT
LO
UIS
UN
IVE
RS
ITY
UN
IVE
RS
ITY
—.
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aint
Lou
isU
nive
rsit
yS
choo
lof
Med
icin
e—
5—
*
*
7In
trod
ucti
on/
Hea
lth
mai
nten
ance
ofpat
ients
wit
hin
flam
mat
ory
bow
eldi
seas
e(I
BO
)is
mul
tifa
ctor
ial
and
ofw
ell-
esta
blis
hed
impo
rtan
ce.
How
ever
,th
eex
tent
that
itis
prac
tice
dan
dw
het
her
the
gas
troen
tero
logis
t(G
l)or
prim
ary
care
prov
ider
(PC
P)w
ould
orsh
ould
assu
me
itsre
spon
sibi
lity
are
not
clea
r.
Met
hods
We
anon
ymou
sly
surv
eyed
aco
nven
ient
sam
ple
of87
inte
rnis
ts(1
1.6%
univ
ersi
tyfa
cult
y,5.
9%V
eter
ans
Adm
inis
trat
ion
(VA
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culty
,82
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ical
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dent
s)an
d50
GIs
(24%
univ
ersi
tyfa
cult
y,14
%V
Afa
cult
y,40
%re
cent
GIgr
adua
tes,
and
22%
Cl
fell
ows
in-t
rain
ing)
who
are
affi
liat
esor
trai
nee
sof
St.
Lou
isU
nive
rsit
y,St
.L
ouis
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isso
uri.
Ele
ctro
nic
orpap
erse
lf-a
dmin
iste
red
inst
rum
ents
wer
eus
ed(r
espo
nse
rate
92.5
%an
d81
.9%
,re
spec
tive
ly).
Con
clus
ion
The
data
indi
cate
sth
atth
ere
are
sign
ific
ant
diff
eren
ces
betw
een
the
per
cepti
ons
ofG
Isan
dPC
Psre
gard
ing
who
shou
ldm
anag
ean
dke
eptr
ack
ofH
Mis
sues
inIS
Opa
tien
ts,
and
that
exce
ptfo
rd
epre
ssio
n/a
nxie
tyan
dsm
okin
g,G
Is’
prac
tice
(alt
houg
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tpe
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aybe
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ific
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yb
ette
r
than
PCPs
’pr
acti
cein
addr
essi
ngth
ese
issu
es.
Who
Sho
uld
Kee
pT
ck
ofH
MIs
sues
?
*
‘no 90
80 70 60 50 40 30 20 to 0
PCI’
shou
ldm
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e
1
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trac
ksh
ould
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k
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1*
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P
010
20
30
40
50
1*
_________
_____________________________________________________________________
Hig
her
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ose.
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ater
good
:
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70
80
9010
0)
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0.05
intr
oduc
tion
IBD
pat
ien
tsar
eat
incr
ease
dri
skof
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cinat
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pre
ven
tab
lein
fect
ions
,w
hich
isex
agg
erat
edby
the
incr
easi
ngus
eof
ster
oid
s,im
munom
odula
tors
and
biol
ogic
s.H
owev
er,
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tcl
ear
wh
eth
erth
e
gas
tro
ente
rolo
gis
t(G
I)or
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prim
ary
care
pro
vid
er(P
CI’
)
wou
ldor
shou
ldas
sum
ere
sponsi
bil
ity
for
vac
cinat
ions
in
this
popu
lati
on
.
Met
hods
We
anon
ymou
sly
surv
eyed
aco
nven
ient
sam
ple
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inte
rnis
tsw
hoar
eaf
fili
ates
ortr
ain
ees
ofSt
.L
ouis
Uni
vers
ity
(SLU
),St
.L
ouis
,M
isso
uri
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iver
sity
facu
lty,
5.9%
Vet
eran
sA
dmin
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atio
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ical
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dent
s),
usin
gel
ectr
onic
orpap
erse
lf-
adm
inis
tere
din
stru
men
ts(r
espo
nse
rate
92.5
%).
Con
clus
ion
The
data
indi
cate
sa
shar
pdi
vide
inSL
Uin
tern
ists
’
perc
epti
onof
who
shou
ldta
kere
spon
sibi
lity
ofva
ccin
atio
n
ofIB
Dpat
ients
and
that
IBD
pati
ents
’va
ccin
atio
nsar
eno
t
adeq
uat
ely
addre
ssed
byin
tern
ists
.T
heap
plic
abil
ity
ofou
r
resu
lts
toin
tern
ists
ino
ther
sett
ings
isun
know
n.W
e
sugg
est
that
gas
troen
tero
logis
tsm
aint
ain
full
resp
onsi
bili
ty
for
vacc
inat
ion
ofIB
Opa
tien
ts.
Alt
erna
tive
ly,
spec
ific
stra
tegi
esca
nbe
util
ized
,su
chas
mor
eex
plic
itguid
elin
es/
nternists
and
EMR
rem
inde
rs&
chec
kpoi
nts.
Vac
cina
tion
sin
IBD
Pat
ients
:In
tern
ists
’P
ract
ice
&P
erce
pti
ons
ofR
espo
nsib
ilit
yM
uham
mad
B.
Ham
mam
iM
D,
Pra
tik
Pan
dit
MD
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ebec
caT
alki
nB
S,K
atie
Sch
roed
erM
DS
AIN
TL
OU
ISS
AIN
TL
OU
ISU
NIV
ER
SIT
YS
aint
Lou
isU
niv
ersi
tyS
chool
ofM
edic
ine
UN
IVE
RS
ITY
NR
espo
nsib
ilit
yof
vacc
inat
ion
in1B
DP
atie
nts
A 5—.
Res
ults
Vac
cina
tion
Fre
qUen
cyin
IBD
Pat
ients
IIE
Who
shou
ldd
ocu
men
t?W
hosh
ould
deci
de?
Who
shou
ldor
der?
•P
C,
•C
I•
PC
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Iem
05
05
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PGIn
In
Com
fort
Lev
elIn
Vac
cina
ting
IOU
Pat
ient
s
0t
.dn
Be
—
2 mn-S
tO
!
hbj
u.n
Hi
Inac
tiva
ted
vacc
inat
ion
live
vacc
inat
ion
ev..yeom
t.nhi.
•lm
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t.I.
sn
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fl.b
b•Ium
nfrfl.
hb
Ass
essm
ent
ofIB
DV
acci
nati
onS
tatu
s
II IIIIIiiiii
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Infl
uenz
a&
Pneu
monia
Vac
cine
sin
180
Pat
ients
11.1
jH
HH
Illi
Hn
mE
a
IIpi
rH
ighe
rpu
rpos
e.G
reat
ergo
od.
SAIN
TL
OU
ISU
NIV
ER
SIT
’t—
rsi.
III
—
Intr
oduc
tion
•C
osm
etic
Inje
ctio
nsbe
com
ing
incr
easi
ngly
mor
epo
pula
r
•L
ittle
dow
nti
me
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hort
Dur
atio
n•
Opt
imiz
epo
stpr
oced
ure
cale
:
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void
non-e
ssen
tial
coag
olan
ts•
Rol
eFo
rA
ntic
sor
Bro
mol
ain?
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rnic
a:A
stem
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fam
ily
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Top
ical
Form
s
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rom
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acat
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osu
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ixed
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lts
inl.
tera
ture
rega
rdin
gef
fica
cyG
rade
DR
ecom
men
dati
on•
Typ
ical
lyw
ell
tole
rate
dw
ith
min
imal
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osit
ive
resu
lts
seen
whe
nad
min
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red
pre-
opan
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nti
nued
For
1-4
days
puss
opC
urre
ntly
ina
pati
ent’
sco
smet
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tati
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edi
scus
sth
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tion
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nti
der
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Ant
ics
orFr
esh
pine
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e/ki
wi
prio
rto
inje
ctio
ns
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hat
doou
rpa
tient
’sdo
with
this
tnfo
rmat
ion?
Obj
ecti
ves
•In
vest
igat
eth
ein
cide
nce
ofar
nica
orbr
omel
ain
supp
lem
ents
prio
rto
cosm
etic
inie
ctio
ns•
Inci
denc
eof
brui
sing
and
the
impa
ctof
oti
sgar
nic
aor
brom
elai
n•
Patie
ntpe
rcep
tions
ofth
ese
prod
ucts
and
reas
ons
toe
avoi
ding
thei
rus
e
Met
hods
____
•P
art’
:W
ritt
ensu
rvey
•P
atie
nts
who
pre
sente
dfo
rco
smet
icje
ctons
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emog
raph
ics,
Ris
kF
acto
rs,
Pre
ven
tati
ve
Beh
avio
rs•
Pan
2:F
ollo
wup
surv
ey•
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tvi
aem
ail
usin
g
Qua
ltri
cssu
rsey
soft
war
e•
Inci
denc
eof
brut
sing
,
Qua
lita
tive
asse
ssm
ent
of
seve
rity
and
loca
tion
oFbr
aisi
ng
Dat
aco
llect
ion:
Apr
ili”
-Ju
ne
2’201]
Sim
ilar
freq
uenc
ies
ofth
eus
eof
prot
ecti
vepr
acti
ces
seen
inbo
thpa
tien
tsw
ithor
wit
hout
risk
fact
ors
Pat
ient
Per
cep
tio
ns
and
Use
ofC
omm
only
Rec
omm
ende
dP
reven
tati
ve
Post
-Pro
cedure
Ecc
hym
osis
and
Ede
ma
Pra
ctic
esP
rior
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osm
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Inje
ctio
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nnif
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lbus
Fehi
man
M.D
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icA
rmbr
echt
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eeA
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ser
M,D
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ain
tL
ouis
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tyD
epar
tmen
tof
Der
mat
olo
gy
Dem
ogra
phic
s:•
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mpl
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tten
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eys
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emal
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roce
dure
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otul
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ller
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ller
&B
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n
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ults
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It
Ass
essm
ent
of
Pote
nti
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isk
Fac
tors
for
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isin
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22%
took
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ilyor
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pres
crip
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bloo
dth
inni
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pple
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clud
ing
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amin
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mpo
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Ris
kF
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rs•
52%
wit
hout
anid
enti
fied
risk
fact
or•
43%
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hon
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ctor
5%pa
tien
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ith
two
risk
fact
ors
Ass
es5
men
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Bru
isin
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ith
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kF
acto
rs
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tect
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Pra
ctic
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isin
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ual
itat
ive
Ass
essm
ent
of
Bru
isin
g
F.
Bru
isin
gw
asid
enti
fied
atin
ject
ion
site
sby
all
pati
ents
wit
ha
brui
se(n
44
)
50%
ofpa
tien
tsde
scri
bed
min
imal
whase
a,br
uisi
ng
Ap
pe:
rsth
atpr
otec
tive
fact
ors
did
not
----.I
Ide
crea
sein
cide
nce
ofbr
uisi
ngW
hy
don’t
our
pati
ents
use
pre
venta
tive
pra
ctic
es?
tn_it
—h
st,d
ed
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on
One’s
-
.M
:W;o
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tco
ibts
lsei
-
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at
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ient
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ient
and
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eth
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ient
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terv
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atw
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tion
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neo
nat
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ent
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us
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s
mm
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ary
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eica
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ican
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ttit
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ere
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ants
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ith
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enio
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rtte
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ith
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ure
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yIn
4(3
6%)
pati
ents
ing
rtu
p
6co
mpa
red
to1(
12.5
%)
pati
ent
ingr
oup
I(P
oa.3
3).
Dis
cuss
ion
•O
urs
bein
gre
troo
pect
ive
chad
stud
yov
ertS
year
spe
riod
,2
grou
pr
had
var
iable
per
iod
stf
toll
ows
ups.
•R
arity
ofdi
seas
eoc
curr
ence
cont
ribu
ted
toli
mit
atio
nin
sam
ple
sioe
mak
ing
achi
esm
ent
ofus
alis
tical
sig
nd
ian
cedi
ffic
ult
for
som
eco
mpa
riso
ns.
•O
urs
isth
efi
rst
stud
yto
inve
stig
ate
the
saIn
tpe
tmis
sibl
ere
sidu
al
pres
sure
grad
ient
sto
min
imie
elh
erei
tty
rven
tlo
nra
teas
wel
las
impa
cttI
ball
oon
site
onth
elo
ngte
rmou
tcom
esin
thes
epa
tien
ts.
Con
clus
ion
•C
onw
rsab
neba
boon
niae
6m
mis
idea
lto
ache
emad
equat
em
et
ofpr
essu
reg
rad
ent
(530
nun
Hg)
&pi
n-m
ice
aoat
icte
gwgi
eati
os.
•R
epea
tbat
non
aonkvah
ealo
pla
sty
may
beex
pect
edw
ith
this
cmss
ervat
hea
ppm
act
but
inth
elo
ngtu
nis
preF
era
DOe
over
surg
ical
inte
rven
tion
for
tonic
rego
rgit
asio
nw
hen
Ia13
crb
ato
on
sioe
was
use
d.
•O
urm
essa
gein
repea
tper
cuta
neo
us
bal
oon
acet
icval
mlt
p(a
sty
isbenn
thee
,ac
etic
valv
ere
pla
tem
ent
tutg
evy
orR
oss
oper
atio
n
Refe
ren
ces
I.eo
n.’
erameern
iCla
ret
04onaL
enda
cca
noenra,
tts-
iot.
a.elm
en
Raceet
no
tice,
i.e
aIcsa
cet
lwtn
aaa.a
au
.I
velo
ti.l
.cceavB
wte
eunsaonaL
aara
caia
t,m
.et
-tan
a-ta
aoa
care
.oa
drm
eato
.bss
iemsla
eadce
ea,t
taveca
coca
eol.t
nftr.
lO-o
o5
Befla
. aew
lent
C,vio
neta
rceltta
an1
59
5*
0aI
x.l.
eae.d
ctt
aed
rtth
iirs
la.
Hnwanc
.e,as
aenca
,eoa
mts
iaaz
wsl
awn.
Impac
tof
Bal
loon
Size
onO
utc
om
esin
Neo
nat
esw
ith
Cri
tica
lA
orti
cS
teno
sis
mA
nin
stit
uti
onal
exp
erie
nce
Man
ish
Mal
kar
MD
MPH
and
Saa
deh
Jure
idin
i,M
D,
Sai
nt
Lou
isU
nive
rsit
y,S
t.L
ouis
,M
O
Aut
hors
have
nodi
sclo
sure
s
•M
tder
ate
tose
vel
eA
R
Mil
dA
R
______
______
•N
oor
Tra
ceA
RP0
0.00
.4
Impa
ctof
ball
oon
sloe
onth
efr
eque
ncy
ofre
lnte
rven
tlon
for
aofl
icre
sten
osin
and
regu
rgIt
atIo
n
to
—
.—
•b
nsm
fll
llli
.ill
r
——
—.
.
BL
etn
sllie
Pt
(so
so
Aim
s&
Hyp
othe
sis
43 95 00 so
—n
t5
Iw
0 0 a E C
oM
oder
ate
to.5
enee
eA
R
-•
No,
trac
eop
mild
AR
00
—-r
——
•ei
e.m
iovla
ov
eta
r&eel
•Pe
o-na
hilo
dam
lP
eacu
en
flfO
VA
F<
awe
Outc
om
esof
Goa
lsof
Car
eC
on
ver
sati
on
sw
ith
Hosp
ital
ized
Vet
eran
sfr
omP
alli
ativ
eC
are
Co
nsu
ltat
ion
sC
amer
onS
imm
ons,
MD
1;S
ukes
hM
anth
ri,
MO
’;O
scar
A.
Cep
eda,
MO
21.
Fello
w.
Hos
pice
and
Palli
ativ
eM
edic
ine,
Sain
tL
ouis
Uni
vers
ity,
Si
Lou
is,
MO
,U
SA.
2.A
ssis
tant
Pro
fess
or,
Hos
pice
and
Palli
ativ
eM
edic
ine,
John
Coc
hran
VA
Hos
pita
l.SI
.L
ouis
,M
O,
USA
.
Bac
kgro
und
•In
patie
ntpa
lliati
veca
re(IP
C)co
nsul
tatio
nse
rvic
esha
vebe
enwi
dely
adop
ted
inUS
hosp
itals.
•O
utco
mes
rese
arch
has
dem
onst
rate
dim
prov
edqu
alily
oflif
efo
rpal
liativ
ein
patie
nts
for
sym
ptom
cont
rola
ndsa
tisf
tio
nwi
thca
m.
Farn
ities
bene
fited
from
en’o
tiona
lsu
ppor
t,ca
mpl
anni
ng,a
ndtra
nsiti
ons
ofca
re.
Out
com
esin
clud
ing
hosp
ital
leng
thof
stay,
hosp
italc
osts
,an
ddi
scha
rge
disp
ositi
onal
soap
pear
toim
prov
e.•
VApr
ovid
espa
lliat
ive
cam
(PC)
cons
ulta
tion
team
sat
allits
hosp
itals
natio
nwid
e,al
thou
ghsu
chse
rvic
esal
epr
ovid
edat
only
ahou
ton
efo
urth
ofall
Am
eric
anho
spita
ls,
how
ever
tew
stud
ies
exist
tosh
owho
wa
PCse
rvic
eis
utili
zed
ata
VAho
spita
l.•
This
study
ofon
ePC
cons
ult
team
atan
urba
nVA
prov
ides
aun
ique
pict
ure
ofho
wth
ePC
team
isut
ilize
d.
Met
ho
ds
•A
retro
spec
tive
study
inw
hich
anin
stitu
tiona
l dat
abas
ewi
tha
tota
lof
130
patie
nts
adm
itted
toVA
hosp
italw
[thse
vere
illne
ssre
sutli
ngin
PCco
nsul
twas
revi
ewed
.O
wstu
dyw
asIR
Sap
prov
alen
errp
lIfa
ra’
,ten±
naph
ysic
ian
ke$
trk
ofea
chlP
cer.c
ount
erbe
twee
nSe
ptem
ber2
014
toA
pnl2
016.
i.Pa
tient
char
tsw
ere
revi
ewed
and
the
fakw
ing
kitra
mat
iwi
was
wbc
ted:
age.
patie
ntlo
catio
n,di
agno
sis,
punt
erof
days
betw
een
adni
ssic
tian
dPC
cons
ult
nwnh
erni
days
betw
een
adm
issi
onan
dfa
nily
nwet
thg.
and
chan
gein
goal
sof
care
.M
alys
isw
asce
efrm
edto
desc
dpve
mea
sure
sirm
&jd
bgfr
eque
rSs.
plea
ts,
rang
es,
and
nwdi
ans.
REFE
REN
CES
cwaw
abiA
,Gre
erJA
,Tee
s]JS
.Doe
spa
tatiw
Gao
binp
rave
outc
omes
feypa
tent
sw
ie,
thcn
rtje
Lie
ss?A
rrr,
ewct
u’e
evid
erce
. JSm
.,mlO
ncol
.201
t9fl
):tl.
94.
Hio
gitis
enU,
FtJa
yI,
&od
,ni
CM. e
taDo
hosp
takb
ased
pait
rete
ams
impr
ove
care
icrpa
tient
scr
tres
atth
een
d0!
it?
JPa
inSh
,røan
nM
ar.a
ge.a
{’na
’2)
96-1
06.
ICU
:71
(54.
6%)
Med
ical
orsu
rgic
alflo
or.
57(4
3.8%
)E
mer
genc
yro
om:
1(0.
8%)
Palli
ativ
eca
redt
nic:
1(0.
8%)
Met
asta
tictc
er
(31
pati
ents
,24
%)
Dem
enti
a(2
2pa
tien
ts,
17%
)R
espi
rato
ryfa
ilure
(17
pati
ents
,13
%)
Stro
ke(9
pati
ents
.7%
)S
epti
csh
ock
and
liver
failu
re(7
pate
nts,
5%)
3f;
Oth
ers(
44
pau
ents
,34
%)
Tab
le2:
Sta
tist
ics
base
don
floor
vs
ICU
Consu
ltat
ions
10.4
a60
(83%
)—
11(1
5%)
Z3i
1(2%
)
4(5.
5%)
14 54(7
5%)
34(4
7%)
55(7
5%)
10.8
Li
From
apu
rely
outc
omes
-bas
edis
tew
mta
tion,
PCco
nsut
atio
nw
asas
soci
ated
with
83%
ofpa
tient
sre
ceiv
ing
ach
ange
inco
dest
atus
from
Fut
Ced
eI
TSL-
1.R
emar
kabl
eon
ly3
out
of13
0pa
tient
s(2
%)
expi
red
whi
lein
patie
ntwi
thlul
lco
dest
atus
.K
now
ing
that
Eady
IPC
cons
ultat
ion
bym
edic
alte
ams
impm
ves
qual
ityof
life,
our
data
also
allo
ws
aun
ique
com
paris
onbe
twee
ntim
ingof
PCre
ferra
ls.O
urav
erag
enu
mbe
rof
days
for
initi
alPC
cons
ulta
tion
follo
wing
adm
issi
onw
as3
days
onth
eflo
oran
d7
days
inth
eIC
U.
The
final
stud
yco
ndus
ien
our
team
tell
dese
rved
disc
ussi
onw
asth
atth
em
ajor
ity(7
1.6%
)off
amily
mee
tings
wer
ehe
ldwi
thfa
mily
only
(no
patie
ntin
volv
emen
t).Th
isin
wtie
sa
mis
sed
oppo
rtani
tyto
have
earli
erPC
inve
lvem
ent
whe
reth
epa
tient
them
selv
esco
uld
parti
cipa
te.
This
calls
for
fum
ier
inte
rven
tions
rega
rdin
gea
rlyid
entif
icat
ion
ofth
ese
patie
nts
and
bette
rpe
oces
ses
toas
sist
inth
eir
deci
sion
mak
in
g.
__
__
__
__
__
__
__
__
__
__
__
__
_
Lim
itat
ions
•It
isa
sing
le-in
stitu
tion
stud
yan
dev
ery
orga
niza
tion
has
itsow
nin
tem
alcu
lture
vthe
theat
toU
ased
mss
ttsaw
ayftt
mge
nera
lapç
catir
iy.
Tho4
mth
isstu
dysp
eaks
toth
eef
fect
iven
ess
ctPC
ccos
utai
ic-n
,it
does
oct
strg
uis
hw
tch
outc
cere
sw
ere
speo
rto
PCte
amvs
the
cor,c
onm
ntm
edic
alte
am’s
invo
fvem
enL
•W
eal
sodi
dro
tha
vea
cooc
unen
tor
hist
oric
alco
ntro
lgr
oup
ofden
rgrn
thta
tysir
t,an
deq
uiva
lend
yI
patie
nts
for
who
mpa
Latin
em
aisu
tabo
nw
asno
tre
ques
ted.
Conclu
sions
•IP
Cam
utili
zed
timel
y(3
days
floor
,7
days
CU),
arid
resu
ltsin
chan
geof
code
jst
aus
in83
%of
patit
nts
(with
onfy
2%of
patie
nts
enpi
vivi
gas
fut
code
whi
eirp
atie
nt).
Stud
yal
sosu
ppon
sor
.gcL
igirp
pmve
nwnt
for
eam
fer
PCin
terv
ent,t
nas
71.6
%of
fasw
iym
eetin
gsw
ere
held
w,th
out
the
patie
nt.
whi
chhh
hght
sth
evt
th&
abJr
jcf
the
nwdk
ally
utho
fren
ded
patie
nts
inth
eVA
setti
ng.
Tab
le1:
Pat
ien
tC
hara
cte
rist
ics
72.4
year
s
5.2
days
Ave
rage
age
Ave
rage
no.
ofda
ysfo
rPC
alte
rad
mis
sion
Pat
ient
loca
tion
Dia
gnos
is
Dis
cuss
ion
--
a;
57 75.0
3.1
72 70.2
7.0
6.4
48(8
4%)
-
Med
ical
vSur
gica
lF
loor
Icy
y_aqe
Ag
e
__
__
__
__
__
__
__
Ave
rage
num
ber
ofda
yaCo
IPC
consu
ltat
ion
No.
ofda
ysfo
rFM
sinc
ead
mis
sion
Initi
alco
de
Sta
tus
TSL-
1D
NW
DN
IT
SL.3
lbacuss
ion
With
Pt
Ont
yPt
&F
amil
yF
amil
yon
lyG
OC
chan
ge
afte
r1”
FMH
ospi
ceat
Dis
char
geN
o.of
Day
saf
ter
1’FM
__
__
__
__
__
__
9(16
%)
0(0%
)
2(3
.5%
)17
(30%
)38
(66%
)33
(58%
)47
(82%
)1
32
Pro
spec
tive
,bl
inde
dev
alua
tion
ofte
mpl
ate-
base
dce
sare
ando
cum
enta
tion
erro
rin
anob
stet
ric
trai
ning
prog
ram
Abst
ract
Obj
ecti
ve:
Ces
area
nop
erat
ive
repo
rtac
cura
cypo
tent
iall
yIm
pact
sbo
thpo
stop
erat
ive
care
arid
futu
reob
stet
ric
deci
sian
-mak
ing,
Wr
aim
edto
desc
ribe
the
accu
racy
ol
resi
dent
cesa
rean
oper
ativ
ere
port
sin
then
ofel
ectr
onic
heal
thre
cord
tem
plat
es.
Stu
dyD
esig
n:T
his
proj
ect
wit
unde
rtak
enas
aqu
alit
yim
prov
emen
tin
itia
tive
,and
as
such
,w
asno
tap
prov
edby
an
156.
Att
endi
ngph
ysic
ians
wer
eag
edto
com
plet
ea
stan
dard
ized
audi
tfo
rmfo
Ilow
ingcran
deli
veri
esw
hich
was
com
pare
dto
the
unco
rrec
ted
resi
dent
oper
ativ
ere
port
.E
rror
sw
ere
clas
sifi
edas
none
,m
ajor
,or
min
or.
Maj
orer
rors
incl
uded
erro
rsw
ith
pote
ntia
lto
affe
ctpe
riop
erau
ise
man
agem
ent
or
InfI
uen
cefu
ture
obst
etri
cm
anag
emen
tw
hile
min
orer
rors
did
not
hav
esuc
hpo
tent
ial.
Aut
hor
and
oper
ativ
ech
arac
teri
stic
sw
ere
coll
ecte
dfo
ram
par
atie
eand
pred
icti
ve
anal
yses
.
Res
ults
:W
ere
view
ed10
0ce
sare
ano
per
ativ
ere
po
rts
over
a6
mo
nlh
peri
od.
Maj
or
erro
rw
asid
enti
fied
In33
%an
dm
ihsr
erro
rw
anId
enti
fied
in53
%o
fo
per
ativ
en
ote
s.
Adv
anci
ngtr
ainI
ngle
velw
itas
soci
ated
wit
hlo
wer
inci
denc
eof
maj
or50
%,
for
PGv
1,
33%
foe
POT
2.an
d0%
for
P013/I
.pa
.021
.b
ut
no
tm
sor
(45%
,53
%,
70%
for
Poll
.
P0v
2.an
dP
013
64,
ctw
.Iy
a43
)d
ocu
men
tati
oner
rors
.O
per
ativ
ed
ura
tio
n,
do
oam
enta
tio
nin
tew
al,
arid
s5th
char
acte
rinti
csw
ere
sim
ilar
inca
ses
wit
han
dw
ithout
do
cutn
enta
tio
ner
rors
.In
mu
ltip
lelo
gist
icre
gres
sIon
,p
ost
gra
du
ate
fear
wan
pred
icti
ve
of
maj
ord
ocu
men
tati
on
erro
r(a
Ct
0.39
,9
5%
O0
.17
.0.9
2),
wh
ence
,o
per
ativ
eta
me
laO
S1.
0195
%0
0.98
.1.0
3),d
ocum
enta
tion
inte
rval
(aO
R1
95%
00
.99
6.1
.00
3),
shif
t
dura
t:on
(vO
te2.
5695
%00.5
412.1
1),
end
shif
tty
pe
(aO
R0.
6295
%00.1
9.1
.95)
wer
e
not
paed
;cti
ve.
Coe
dsis
lom
Ahi
ghIn
cid
ence
of
clin
ical
lysi
gnif
ican
tdocu
men
tati
oner
ror
was
ob
serv
ed
nar
esid
ency
trai
ning
prog
ram
usin
gst
anda
rdiz
edte
mpl
ates
for
cesa
rean
oper
ativ
e
repo
rts.
Inci
denc
eof
maj
orer
rord
ecre
ased
wit
hin
crea
sing
trai
ning
,bst
min
ore
rro
rwas
sim
ilar
acro
stle
vels
oft
rain
irg,
sugg
esti
ngth
ater
rorm
ayhe
aco
nseq
uenc
eof
met
hod
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0.,
Mo
call
,i.r
,J.
Oeb
y,.n
d
eU
jd.,n
inC
.b
ren
thm
rep
y‘o
lIn
:p
qg
.pli
xn
rre.t
.re
alty
.lo
smI
offr
sldld
o(y
&in
ltrw
stio
n&
pah
ns.,Ix
cf
flIt
:1
I:3
09
-33
7
•O
urpe
rcep
tion
ofsi
gnif
ican
tde
lays
inth
ebr
onch
osco
pysu
ite
was
tran
slat
edin
toob
ject
ive
data
-O
ured
ucat
iona
lin
terv
enti
on
resu
lted
inim
prov
edef
fici
ency
espe
cial
lyin
proc
edur
est
art
tim
ean
dti
me
the
proc
edur
eH
&P
was
sign
ed-
Asi
gnif
ican
tnum
ber
ofp
roce
du
res
cont
inue
tobe
dela
yed
Our
resu
lts
are
cons
iste
ntw
ith
prev
ious
lypu
blis
hed
lite
ratu
reth
atl
iden
tifi
edth
ep
re-p
roce
du
repe
riod
asth
em
ain
sour
ceof
dela
ys•
More
qual
ity
imp
rov
emen
tin
itia
tives
are
nee
ded
toid
enti
fya
diff
eren
tw
ork
flow
that
wou
ldim
prov
eth
efl
owin
the
bron
chos
copy
suit
e,es
peci
ally
inth
epie
-pro
cedure
peri
od
Lar
yngo
trac
heal
cLef
tin
anin
fant
wit
hco
mpl
exco
ngen
ital
card
iac
defe
cts.
..
Kat
eLin
Sta
mm
,D
O,
Phil
Mue
tlerL
eiL
e,M
D,
Nai
laA
hmad
,M
D,
Mar
ion
Sve
ndro
wsk
i,M
Dp
iil
l1%
Dep
artm
ent
ofA
nest
hesi
olog
yan
dC
riti
cal
Car
eM
edic
ine,
Sai
ntL
ouis
Uni
vers
ity
Sch
ool
ofM
edic
ine,
St.
Lou
is,
Mis
sour
i
Cas
eR
epor
tC
onti
nued
Intr
od
uct
ion
Lar
yngo
trac
heaL
cLef
ts(L
C),
aco
ngen
ital
defo
rmit
yof
the
post
erio
rpo
rtio
nof
the
Lary
nxan
dtr
achea
,ar
ea
rare
and
ofte
nch
alL
engi
ngco
ngen
itaL
airw
aym
aLfo
rmat
ion.
Occ
urri
ngin
ever
y10
,000
-70,
000
Live
birt
hs,
LCs
cann
otbe
diag
nose
dpr
enat
aLly
,an
dar
eus
uaLL
yfo
und
whe
nsy
mpt
oms
man
ifes
t.W
ep
rese
nt
am
uLti
-sta
ged
case
stud
yof
aneo
nat
ere
quir
ing
surg
ical
corr
ecti
onof
card
iac
anom
aLie
sw
ith
aLa
ryng
eaL
cLef
tth
atw
asdi
agno
sed
onin
itiaL
intu
bati
onat
tem
pts
.
Und
erdir
ect
visu
aLiz
atio
na
2.5
mm
uncu
ffed
rrr
was
plac
edin
the
righ
tm
ains
tem
and
ano
ther
was
pLac
edin
the
Left
mai
nste
m.
AY
adap
tor
was
connec
ted
tobo
thtu
bes
and
both
Lung
sw
ere
vent
iLat
ed.
Whe
nth
err
rw
asw
ithd
raw
na
Larg
eLe
akw
asno
ted.
Fur
ther
atte
mp
tspr
oduc
edsi
miL
arre
suL
ts.
A3.
0m
mrr
rw
asth
enm
ain-
stem
med
inor
der
tov
enti
late
the
pat
ien
t.A
nem
erg
ent
bron
chos
copy
reve
aLed
aT
ype
IIILa
ryng
eaL
cLef
t.D
ueto
the
urge
ntne
edfo
rca
rdia
cre
pai
ran
ddi
ffic
uLty
inve
ntil
atin
g,th
e[N
Tsu
rgeo
npe
rfor
med
are
pair
ofth
eLC
.T
hepat
ient
was
tran
sport
edto
the
ICU
wit
ha
3.0
mm
uncu
ffed
ETT
inpl
ace.
On
day
9of
Life
,sh
eun
derw
ent
card
iac
repa
ir.
Pos
t-op
erat
iveL
y,sh
ew
asdi
ffic
ult
tove
ntiL
ate
and
her
ches
tx-
ray
show
edw
hit
eou
tof
her
Left
lung
.R
epea
tbr
onch
osco
pyid
enti
fied
that
her
clef
tre
pair
had
brok
endo
wn
due
topr
oLon
ged
intu
bati
on.
She
was
plac
edon
ECM
Osu
ppor
tdu
eto
vent
iLat
ory
and
hem
odyn
amic
inst
abiL
ity.
The
rew
asco
ntin
ued
diff
icuL
tyw
ith
endo
trac
heaL
tube
pLac
emen
tdu
eto
ade
epcl
eft
and
shor
ttr
achea
sosh
ere
turn
edto
the
OR
for
abr
onch
osco
py,
whi
Lesti
LLon
ECM
O.
Ifsi
gnif
ican
tre
spir
ator
ydi
stre
ssnec
essi
tate
sen
dotr
achea
lin
tuba
tion
,th
engre
atca
resh
ouL
dbe
taken
whe
npl
acin
gth
eE
Ras
prop
erpla
cem
ent
can
bedi
ffic
uLt.
Bro
ncho
scop
icgu
idan
cesh
ouLd
beus
edto
guid
epo
siti
onin
g.Ea
rLy
extu
bati
onis
enco
urag
edin
repa
ired
LCs
beca
use
proL
onge
din
tuba
tion
can
deL
ayhe
aLin
gof
the
repai
rsi
te.
Dis
cuss
ion
Lar
ynge
alcl
efts
have
been
char
acte
rize
dby
am
odif
ied
Ben
jam
inan
dIn
gLes
scaL
ein
tofi
vety
pes
(O-I
V)
rang
ing
from
asu
bmuc
osat
clef
t(0
)to
acl
eft
whi
chm
ayex
tend
toth
eca
dna
(IV
).W
ithty
peIII
,or
IVLC
s,su
rgic
alre
pair
isof
ten
com
pLic
ated
,re
quir
ing
muL
tipLe
revi
sion
s,w
ith
ahi
ghra
teof
mor
bidi
tyan
dm
orta
lity
.P
rope
rve
ntil
atio
nis
ofut
mos
tim
port
ance
inth
ese
pat
ients
,to
pre
ven
tas
pira
tion
and
puL
mon
ary
com
pLic
atio
ns.
Cas
eR
epor
tO
urp
atie
nt
isa
one
day-
oLd
fuLl
term
fem
aLe
wit
hto
tal
anom
aLou
spu
Lm
onar
yve
nous
retu
rndi
agno
sed
pren
atal
ly.
She
pre
sente
dfo
rre
pai
rof
TAPV
Ron
day
one
ofLi
fe.
She
was
indu
ced
and
vent
iLat
edun
even
tfuL
Ly.
A3.
0m
mcu
ffed
end
otr
achea
ltu
be
was
intr
oduc
edin
toth
etr
ach
eaan
dap
pea
red
tobe
mai
n-st
emm
ed.
Con
clus
ion
Lar
ynge
alcL
efts
are
ach
aLle
ngin
gco
ngen
ital
airw
ayde
form
ity
Dif
ficu
Ltie
sin
endotr
achea
ltu
be
pLac
emen
tan
dve
ntiL
atio
nfr
eque
ntL
yoc
cur
inm
ore
sign
ific
ant
clef
ts.
Cre
ativ
eso
luti
ons
such
asE
fls
inea
chm
ains
trea
mbr
onch
usm
aybe
nece
ssar
yto
achi
eve
adeq
uat
eve
ntiL
atio
nan
dox
ygen
atio
n.
t
Refe
r,.,..
Lrt
rJa,q
rr.
N.
et
al.
Ury
ng
o-’
ncti
eo
-oe,o
ph
an
I[1
,111
.O
wa,
anet
Jma,
,at
IfR
are
1Q11
;6:
SI.
i.,,,.
Aie
ny
prc
aie,
m6’
Ner.
iatn
—A
64
.w‘th
e(r
ecent
ii,r
eltl
gat
km
and
WM
nIe
ceR
,lt
SIf
lIe*$.
FR
on
tie.
,hi
Ped
iati
xs.
Ill’
;5
:50
.S
aprã
a6
l’am
jer
PM
’nco
pic
bo
ng
ntj
.ttt
.fdcii
,.v.i
,en
thouI
tracft
ott
flW
orth
uk
aIc
rI.
tny
ee.s
op
..1
;lI
e:61
0614
.50cr.
,.tel.’
.s
e.p
e’ln
,6’
two,n
ciIw
eIV
flso
uarf
ron
or*
aIe
&c[d
lM
ICt
w,T
hIta
ç,e
.tci
tagA
ncp
haq
ni
.fre
ui.
OwP
al,
xa,
Mec
xaI
.io
inai.
Ill?
;16
:55.
SA
INT
LO
UIS
UN
IVE
RS
ITY
SCH
OO
LO
FM
EDIC
INE
-a
-a
Figu
re2.
Pat
ient
Cha
ract
eris
tics
.A
ge/t
ime
reco
rded
inye
ats.
B/L
=bila
tera
l.R
Hig
ht,
Lae
ft
IFigu
re1
MRI
ofpr
ior
righ
tm
idbr
ain
cave
rnom
ain
Pat
ient
I(l
eft
imag
e).
MRI
nfM
Sle
sion
sin
brai
nste
mof
Pat
ient
B(r
ight
imag
e).
L*tdb1t
•IR
S
•P
a,
,sta
Sm
s
Sai
ntL
ouis
Uni
vers
ityH
osp
ital
;
AIN
TL
OU
lU
NIV
ER
SIT
t
Cas
eP
rese
nta
tion
An
18-y
ear’
old
mal
ew
ithPM
Hof
diab
etes
mel
litus
type
Ian
dde
pres
sion
was
tran
sfer
red
from
outs
ide
hosp
ital
for
a3-
4w
eek
hist
ory
ofw
orse
ning
,pa
infu
l,fo
ul-s
mel
ling
bila
tera
llo
otul
cera
tions
,D
urin
gth
epr
eced
ing
10m
onth
s,he
had
inte
rmit
tent
epis
odes
ofse
vere
pain
ful.
swol
len,
red
feet
that
wor
sene
dw
ithhe
atan
dim
prov
edw
ithco
ldan
del
evat
ion.
He
was
teen
inED
mul
tiple
times
and
give
nan
tibio
tics
for
‘bila
tera
lce
llulit
is”
with
min
imal
impr
ovem
ent.
His
sym
ptom
sbe
cam
eso
bad
heco
uld
long
erw
alk
and
drop
ped
out
ofsc
hool
.Fo
r2-
3m
onth
spr
ior
toad
mis
sion
,pa
tien
tst
arte
dso
akin
ghi
sfe
etin
ice
bath
s(1
’ep
som
salts
)20
-24
hour
spe
rda
y.O
nem
onth
late
r,he
note
dde
velo
pmen
tof
“dar
kre
dsp
ots”
and
‘ulc
ers”
onhi
sfe
etth
atw
orse
ned
desp
ite
stop
ping
ice
bath
s.H
esa
wpo
diat
ryw
hose
nthi
mto
the
EDfo
rfu
rthe
rw
ork
up.
05K
EDst
arte
dtig
ecyc
line,
trea
ted
for
DK
A/s
epsi
s,an
dtr
ansf
erre
dto
Sain
tLo
uis
Uni
vers
ityH
ospi
tal.
PMH
x—D
M1
(sin
ceag
e6,
prev
ious
poor
cont
rol)
,de
pres
sion
No
PMH
ofR
ayna
ud’s
,liv
edo,
nodu
les,
live
r/ki
dney
prob
lem
s,ne
urop
athy
,lu
pus
Fam
He
—N
oau
toim
mun
eor
clot
ting
diso
rder
s,N
oer
ythr
omel
atgi
a
Soci
alH
e—
Smok
esva
por
ciga
rett
es,
No
alco
hol/
drug
s,H
asta
ttoo
s
Med
s—
Intu
tingl
argi
ne34
UO
HS,
Insu
linlis
pro,
Am
itrip
tylin
e50
mg
OH
S(s
tart
ed1
mon
thpr
ior
toad
mis
sion
),M
orph
ine
XR15
mg
BID
Rev
iew
ofsy
stem
s:Po
sitiv
efo
r:pa
in,
burn
ing,
puru
lent
disc
harg
e,lim
ited
RO
Mof
feet
,fe
ver,
tatt
oos
Neg
ativ
efo
r:ch
ills,
naus
ea,
vom
iting
,ac
tive
blee
ding
,ra
shes
PERT
INEN
TLA
BSA
ND
IMA
GIN
G:
Out
side
Hos
pita
l:W
BC
24K
,ES
R10
3(0
’lS
),C
lIP9.
4(<
0.5)
,gl
ucos
e32
3,H
bA1C
6.6%
Bila
tera
lFo
otX
’ray
s—
nega
tive
for
oste
omye
litis
5LU
HLa
bs:
WU
C18
K,
Neu
ts70
%,
Hgb
12.2
,M
CV
85,
PIt
342
UAtr
ace
prot
ein,
trac
eke
tone
s,gl
ucos
e70
C3/
C4,
c-A
NC
A,
p-A
NC
A,
MPO
/P11
3,A
NA
,ds
’DN
A,
ASO
,RF
all
norm
alH
epC
nega
tive
,H
IVne
gati
veB
lood
cult
ures
:ne
gati
veW
ound
cult
ure:
+MSS
Aan
dgr
oup
Ast
rep
Tis
sue
cult
ure:
+MSS
A,
Ste
notr
opho
mon
asM
alto
phili
a,D
ipht
hero
ids
Cry
oglo
bulin
s:ne
gati
ve(r
epea
ted
toen
sure
nofa
lse
nega
tive
)
Concl
usi
on
—-—
FIN
AL
DIA
GN
OSI
S:C
ryog
lobu
line
mia
(fea
ture
sof
type
sla
nd
Il/Ill
)an
dco
ldw
ater
imm
ersi
onin
jury
(‘tr
ench
foot
”)tr
igge
red
byfr
eque
ntic
eba
ths
offe
et(t
otr
eat
sym
ptom
sof
eryt
hrom
elal
gia
vs.
neur
opat
hy)
inth
ese
ttin
gof
DM
Typ
e1
Tre
atm
ent/
Fo
llo
w-U
pPa
tient
was
disc
harg
edhone
onan
tibio
tics
with
deea
ning
chan
ges
byho
me
heal
th,
and
was
enco
urag
edto
keep
feet
war
man
dou
tof
Ice.
‘No
spec
ific
trea
tmen
tfo
rcr
yogl
obut
inem
ia,a
tthe
rew
ere
nosi
gns
ofsy
stem
icin
volv
emen
tand
eone
wcu
tane
ous
lesi
ons,
‘Im
prov
edul
cers
onsk
ines
amat
F/U
.r
U
__
__
__
__
__
__
__
_
Ref
eren
ces
Intr
od
uct
ion
/Bac
kgro
und
AU
niqu
eC
ase
ofC
old
Wat
erIm
mer
sion
Inju
ryan
dC
ryog
lobu
line
mia
Kav
itaD
arji,
MD
’,C
ourt
ney
C.C
ride
r,M
D2,
Mal
lory
Aba
te,
MD
2,T
rici
aA
.M
issa
ll,
MD
,Ph
D2
Sai
ntL
ouis
Uni
vers
ity
Sch
ool
ofM
edic
ine,
‘Dep
artm
ent
ofIn
tern
alM
edic
ine,
2D
epar
tmen
tof
Der
mat
olog
y
•E
ryth
rom
elal
gia
invo
lves
red,
hot,
pain
tul
extr
emiti
es,
spec
itica
llyth
efe
etan
dle
gs.
Toim
prov
eth
ispa
inan
dco
olth
eir
legs
,pa
tien
tsm
aype
rfor
mex
trem
ebe
havi
ors
invo
lvin
gov
erus
eof
ice,
cold
wat
er,
and
fans
.A
lthou
ghth
ese
acti
ons
prov
ide
thor
t’te
rmre
lief,
they
dam
age
skin
unity
and
may
caus
eIm
mer
sion
foot
,m
anif
estin
gas
“cya
notic
,m
ottle
dco
lora
tion,
edem
a,m
acer
atio
n,bu
llae,
eros
ions
,an
dpa
infu
lul
cers
”.
Cry
oglo
bulin
emic
vasc
uliti
sor
mix
ed-t
ype
cryo
glob
ulin
emia
isa
smal
l-ve
ssel
vasc
uliti
sof
the
skin
,joi
nts,
peri
pher
alne
rvou
ssy
stem
,an
dki
dney
sth
atoc
curs
due
toin
fect
iout
,au
toim
mun
e,an
dm
alig
nant
proc
esse
s.H
epat
itis
Cvi
rus
(KC
V)
infe
ctio
nis
the
mai
nca
use
ofth
em
ixed
diso
rder
.
Csy
oglo
bulin
test
ing
invo
lves
prop
erco
llect
ing
and
hand
ling
ofbl
ood
atin
dica
ted
tem
pera
ture
s.Th
isis
impe
rativ
eto
ensu
ring
accu
rate
resu
ltsan
dav
oidi
ngfa
lse
nega
tives
.
PHY
SICA
LEX
AM
Vita
ls:
BP13
0/75
Puls
e12
2IT
emp
100.
9‘F
IRes
p16
IHt
6’IW
t11
8lb
I5p0
298
%IB
MI
16kg
/m2
lIEN
:A
wak
ean
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ert,
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ute
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ful
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ition
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oga
llops
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l:A
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erou
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ous
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ost
with
over
lyin
gbr
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ust
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ew
ithm
ildye
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nage
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tera
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feet
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rsal
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toes
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rsal
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imal
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web
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edia
lfe
et,
med
ial
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es,
and
plan
tar
heel
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sion
san
dul
cera
tions
seem
tobe
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ysy
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etri
can
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ssh
arp
cut
off
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kles
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mth
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t>
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orse
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with
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vatio
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anbe
due
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rom
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s(t
ype
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ilial
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thic
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,2/
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othe
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uses
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toim
mune
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ases
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yelo
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icat
ions
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c).
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ents
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Type
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dal
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ciat
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reso
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ifin
citin
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ors
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ded.
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ater
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jury
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renc
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ueto
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eque
ntul
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tion
s(+
j”ne
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is).
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agem
ent
invo
lves
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ddr
ying
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gan
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even
tion
.
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oglo
buli
nem
is:
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mim
mun
oglo
bulin
s(c
ryog
lobu
lins)
that
prec
ipita
teat
tem
ps<
37’C
and
diss
olve
w/
rew
arm
ing.
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esII
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ciat
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ith
Hep
C.T
reat
unde
rlyi
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eran
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osup
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tion
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vere
.
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oglo
bulio
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ting
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rans
port
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din
war
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bes,
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omte
mp.
cryo
glob
ulin
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ecip
itat
ebe
fore
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rati
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rum
,le
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gto
fals
ene
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Lab
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ntri
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ore
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ys,
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hen,
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kfo
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ibit
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tify
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ate,
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orm
imm
unof
ixat
ion
elec
trop
hore
sis
iden
tify
type
).R
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rAT
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glob
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test
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TIV
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i
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chbi
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rsal
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ulce
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rH
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+D
IF):
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alne
cros
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ithde
rmal
hem
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age
and
fibr
inth
rom
bi,
CM
S/gr
amst
ain
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stai
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gativ
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ve.
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is,
spon
gifo
rmpu
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es,
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erou
sne
utro
phils
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ith
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rom
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ssel
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cer,
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ever
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proc
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com
plet
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uded
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INT
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IVER
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euke
mia
(CL
L)
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soci
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r(H
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rice
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mon
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orch
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y
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ted
with
high
dose
acyd
ovir
orva
lacy
dovi
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wdose
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nbe
use
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prop
hyla
xis
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even
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ral
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ven
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ide
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2008
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dam
ust
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appr
oved
inV
San
das
soci
ated
with
few
erad
ver
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ents
than
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tmen
tw
ithfl
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e
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ME
TH
OD
S
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airs
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tral
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16
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ithin
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_
A Ben
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e
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lan
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rviv
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eeof
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pes
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ter:
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luda
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enda
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reat
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t—
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Surv
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e(y
ears
)
RES
ULT
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dam
ust
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epa
tien
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ere
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ine
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aini
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nger
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efr
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sis
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ead
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ore
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pes
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fect
ion
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luda
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ning
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men
tsha
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erra
teof
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atfi
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ars
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ivar
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ulti
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ithad
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men
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mor
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ties
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ophy
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ior
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ior
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hin
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oth
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udan
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ndam
uslin
e
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eple
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Fac
tors
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ith
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ter
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tly
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onof
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mat
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tota
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mbe
rof
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atm
ent
pat
tem
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red
due
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prov
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bend
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tine
in20
08an
dlim
ited
follo
w-u
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aila
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for
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port
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azar
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odel
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dto
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uate
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ter
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rapy
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niva
riat
eas
wel
las
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riat
ehaz
ard
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R)
indu
ding
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ties
and
prio
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ON
S
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with
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1(0
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0.02
7vs
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udar
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e
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ttiv
aria
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oxP
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nal
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ard
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R(9
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atm
ent
wit
hB
end
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stin
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019
vs.
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ine
--
--
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rlso
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oman
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ich
emot
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for
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tion
For
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with
Irea
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tof
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with
acyc
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rNat
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endam
ust
ine
asso
ciat
edw
ith
reduce
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teof
her
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er
infe
ctio
ns
com
par
edto
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dar
abin
e•
Dec
reas
edri
skp
ersi
sted
even
whi
leac
counti
ng
for
low
erra
teof
pro
ph
yla
xis
and
hig
her
co-m
orb
idit
ies
•F
utu
rest
ud
ies
sho
uld
eval
uat
eth
eef
fect
ofp
rop
hy
lax
isin
pat
ients
atri
skfo
rher
pes
zost
er
RE
FER
EN
CE
S1
I.M
yis
o,l
vs.M
anag
emer
fofW
detu
sro
irfl
icah
ons
inpat
irr.
isw
ith
dw
nic
lpnci
,ocy
scle
ukem
ia.
Hen
alsW
Igy
So
cH
ensa
rofE
dtr
Pro
gram
.20072007(I
l:522-3
38
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ous
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rren
t
C*Q
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stec
:jo
uso
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xs.
2001
.14(
4140
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cknow
iedgrn
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w,t
xed
ais
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supp
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eO
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gy
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itted
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ewed
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rven
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phic
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terv
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and
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ator
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sts:
CB
C,
com
plet
em
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pane
l,am
ylas
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and
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ile.
Stud
yM
easu
res
Pri
mar
yO
utco
me:
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ectio
nof
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abdo
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alin
jury
thro
ugh
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ma
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dva
lidat
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ings
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ospe
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est
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clus
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Inca
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Perc
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16 14 12 10 S 6 4 2 a Figu
resh
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abno
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usio
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ean
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e
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ork
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icat
ions
•O
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stre
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icks
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resh
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ing
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ppen
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cal
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ith
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ithco
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alap
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se
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ould
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rval
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tes
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mpt
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3.Id
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aybe
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rly
appe
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Stud
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nan
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Ret
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tion
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ient
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anag
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om2010
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atie
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and
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atie
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ient
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mpl
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omes
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xclu
sion
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eria
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lpat
ient
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pan
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trea
ted
atou
tsid
ein
stit
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316
pati
ents
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em
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itia
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onge
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dsig
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gher
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med
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55da
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ithD
OS
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had
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onge
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tno
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eren
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clin
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%S
SM
F0
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no:G
lennon
Impli
cati
ons
Our
stud
yid
entif
ied
that
asu
bset
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tient
sw
ithco
mpl
icat
edap
pend
iciti
spr
esen
ting
with
dura
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mpt
oms
55da
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dno
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ess
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mtr
eate
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ithin
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ecto
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fely
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aged
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itat
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No
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dard
preo
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tive
orin
tmop
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fini
tions
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iciti
s•
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dard
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bsce
ssan
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onof
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ptom
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itis
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inte
rval
appe
ndec
tom
y.•
Pat
ient
spr
esen
ting
with
dura
tion
ofsy
mpt
oms
55da
ysan
dno
absc
ess
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sces
ss
3cm
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ted
with
inte
rval
appe
ndec
tom
yha
vehi
gher
com
plic
atio
nsan
dlo
nger
hosp
ital
stay
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Stud
yM
easu
res
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plic
atio
nra
tes
amon
gth
etw
ogr
oups
with
orw
itho
utab
sces
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ddu
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mpt
oms
onpr
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tati
on.
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dah
Bad
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PH1;
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icho
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rman
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ter
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aged
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ase
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ithpe
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ight
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udy
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able
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ym
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hetu
mor
can
have
vasi
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apel
vic
exte
nsio
n.
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ong-
term
outc
ome
for
child
ren
with
sacr
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mas
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cell
ent
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ife-
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inch
ildre
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ascu
lar
cont
rol
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imiz
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ngtu
mor
exci
sion
.
Obje
ctiv
e
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rate
our
tech
niqu
efo
rla
paro
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icdi
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onof
med
ian
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alart
ery
duri
ngdi
ssec
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rin
two
pedi
atri
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tient
sas
asa
fete
chni
que
tom
inim
ize
risk
ofhe
mor
rhag
e.
Cas
eR
epor
t
Con
clus
ion
Lap
aros
copi
cm
edia
nsa
cral
art
ery
divi
sion
befo
resa
croc
occy
geal
tera
tom
aex
cisi
onof
fers
asa
feap
proa
chth
atcan
redu
ceth
eri
skof
hem
orrh
age
duri
ngtu
mor
exci
sion
.
Ref
eren
ces
Lap
aros
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cD
ivis
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edia
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acra
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rter
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isse
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ator
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reas
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IVE
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oma
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scul
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port
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agem
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irm
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rito
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ith
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the
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tifie
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ere
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ga
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oth
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lla
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med
ian
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al
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ryan
dre
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hout
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plic
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—L
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ysic
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plia
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ted
sin
cou
sead
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rate
sla
dio
n,a
.em
,ob
lden
.—
Ose
C
Dia
ne,
Pdsa
lme,
2011
.131
01la
bls
eM
,cA
tse
nte
e,s
an
&ta
MtL
’,n
a,
e,A
nnsa,t
tle#’e
am
deasre
ieadd,t
es,n
oveag,,oddiaes
loseit
âsd
be
au
ae
bls
ectu
thss
Ped
-aum
Pia,e
nr
20
04N
31,m
W4.
tMd
mcem
,nA
wta
sI,
eaIn
0,Ia
emey
Ces,
,t-m
e,s
s54
Osa
idy
hm
eo.n
wes
CH
eeam
,to
n,n
t,d
a&
s,0
0eta
iaee,e
aN
EaIi
-u.
WI.
1344
e1.s7
1-s3
o
Intr
oduct
ion
Our
obØ
ctiv
ew
asto
dete
rmin
eif
birt
hw
eigh
tof
infa
nts
ofw
omen
with
chro
nic
hype
rten
sion
isaf
fect
edby
rang
eof
ante
part
umbl
ood
pre
ssure
.
Met
hods
Are
tros
pect
ive
char
tre
view
otpa
tien
tsw
ithch
roni
chy
pert
ensi
onat
asi
ngte
tert
iary
care
cent
erw
asco
mpl
eted
.T
hedi
ffer
ence
inb
itw
eigh
tbe
twee
nw
omen
with
mea
nan
tena
tal
bloo
dp
ress
ure
sin
the
syst
olic
rang
eof
<140
mm
Hg
ver
ses
‘l4O
mm
Hg
was
asse
ssed
.A
seco
ndan
alys
isto
asse
ssm
ean
ante
nata
ldi
asto
lic
bloo
dp
ress
ure
of-c
gOm
mH
gve
rsus
>90
mm
Hg
was
com
plet
ed.
Chi
squar
edan
alys
isw
asut
ilize
d,w
itha
P-v
alue
of<0
.05
used
toin
dica
test
atis
tica
lsi
gnif
ican
ce.
Res
ult
sD
ata
from
148
wom
enw
itha
diag
nosi
sor
chro
nic
hype
rten
sion
was
anal
yzed
.T
his
anal
ysis
incl
uded
both
thos
eta
king
anti
hype
rten
sive
med
icat
ions
and
thos
ew
how
ere
not
med
icat
ed.
The
rew
asa
sign
ific
ant
diff
eren
cein
birt
hw
eigh
tin
norm
oten
sive
(<l4
Om
mH
gsy
stol
icor
<90
mm
Hg
dias
toli
c)ve
rsus
hype
rten
sive
preg
nanc
ies,
with
norr
note
nsiv
ew
omen
bear
ing
larg
erch
ildr
en.
Med
ian
bit
wei
ght
for
thos
ew
hoha
dno
rmot
ensi
vesy
stol
icbl
ood
pre
ssure
sw
as3,
00S
gver
sus
2,45
09fo
rth
ose
who
had
hype
rten
sive
aver
age
syst
olic
bloo
dp
ress
ure
s(p
=.00
8).
Med
ian
birt
hw
eigh
tw
as29
97.
5gfo
rth
ose
with
norm
oten
sive
dias
toli
cpr
essu
reav
erag
esve
rsus
1.65
7.5g
who
wer
ehy
pert
ensi
ve(p
<0.
001)
.
Con
clu
5io
nilm
p1ic
atio
ns
Wom
enw
ithch
roni
chy
pert
ensi
onin
preg
nanc
yde
live
rla
rger
babi
esw
hen
bloo
dpre
ssu
res
are
inth
eno
rmot
ensi
vera
nge
duri
ngth
ean
tepa
rtum
perio
d.
Bac
kgro
und:
Chr
onic
hype
rten
sion
effe
cts
1-5%
ofpr
egna
nanc
ies.
Thi
sco
nditi
onin
crea
ses
risk
ofco
mpl
ical
ions
incl
udin
gsu
peri
mpo
sed
pree
clam
psia
,ce
sare
ande
liver
y,bi
rth
wei
ght
<25
00g.
NIC
Uad
mis
sion
,pr
eter
mde
liver
y,an
dne
onat
alde
ath.
Con
clus
ion:
The
rew
asa
sign
ific
ant
diff
eren
cein
feta
lw
eigh
tat
deli
very
bas
edup
onno
rmot
ensi
vevs
.hy
pert
ensi
vebl
ood
pre
ssure
sin
the
ante
pari
umpe
riod
whe
nco
ntro
lling
for
othe
rpo
ssib
leco
nfou
ndin
gva
riab
les.
Thes
eva
riab
les
incl
uded
adm
issi
ondi
agno
sis,
age,
gest
atio
nal
age
atde
live
ry,
and
pre
sence
orab
sen
ceof
diab
etes
diag
nosi
s,
As
ase
cond
ary
outc
ome,
we
anal
yzed
diff
eren
ces
betw
een
syst
olic
bloo
dpre
ssure
sbas
edup
onty
peof
anti
-hyp
erte
nsiv
em
edic
atio
n.A
sign
ific
ant
diff
eren
cein
syst
olic
bloo
dpr
essu
rew
asno
ted
betw
een
thos
ew
how
ere
taki
ngtw
oan
tihy
pert
ensi
vem
edic
atio
nsan
dth
ose
taki
ngno
ne(p
<.0
1)as
wel
las
thos
ew
how
ere
taki
ngtw
oan
tihy
pert
ensi
veag
ents
and
thos
eta
king
Now
asc
(p.0
1).
Ref
eren
ces:
1,Fa
ilin
mea
nar
teria
lpr
essu
rean
dfe
tal
grow
thre
stri
ctio
nin
preg
nanc
yhy
pert
ensi
on:
anup
date
dm
etar
egre
ssio
nan
alys
ts.
JO
bste
tG
ynae
col
can.
2002
Dec
;24(
l2).
941-
s.2.
Les
s-tig
htvs
.T
ight
Con
trol
ofH
yper
tens
ion
inP
regn
ancy
NE
ngi
JM
ed20
15:
372:
407-
417
3.C
hron
icH
yper
lens
ion
and
Pre
gnan
cyO
utco
mes
.O
MJ
201k
348g
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The
Effect
of
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rm
otensive
Antenatal
Blo
od
Pressure
of
Wo
men
with
Chronic
Hypertension
on
Neonatal
Weight.
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igh
San
der
.M
D.
Jennif
erG
oldk
arnp
.LI
D.
Lau
raV
rice
lla.
MD
.H
enri
Rose
nb
erg
.85
St.
Lou
isU
nive
rsit
y.S
choo
lof
Med
icin
e
Abs
trac
t:St
udy_
Des
ign:
___________________________
Ret
rosp
ecti
veco
hort
stud
y.In
clus
ion
Cri
teri
a:-
Pre
viou
sdi
agno
sis
ofch
roni
chy
pert
ensi
on-
Doc
umen
ted
bloo
dpr
essu
re‘1
4019
0at
<20
wee
ksge
stat
ion
Exc
lusi
onC
rite
ria:
-N
ohi
stor
yof
hype
rten
sive
dis
ease
-G
esta
tional
hyper
tensi
on,
pre
edam
psi
a,
HE
LL
P,
ed
am
psi
a
P
Syst
oli
cB
lood
Pre
ssure
:
Res
ults
:
M..n
Stc
lkB
Pby
HT
hMtd
S4f
ln
0 0
2T
Otig
.ft
Ad
LtM
?K
iNO
tteIt
(Ow
Hil
leel
HP
(;ro
iip
Med
ian
Bin
IiW
eigh
t(1
Q11
)P—
min
e
<11
03
lRfl
(230
0.34
20)
DiE
S
>14t)
2454
)(1
647.
&29
G{)
Dia
stol
icB
lood
Pre
ssure
:
HP
Media
nB
irth
\‘ei
gIs
t(1
Q11
)P
—nin
e
<II
I2
99
75
(230
&T
h.33
91.5
)<0
(14)
1>
=9()
lsr,
7.5
(Hk
2.5
.24
3I.
25
)
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ift
Wei
gh
tby
OP0rt
7S
n
a
op
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ando
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am,
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ecto
rO
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ache
lle
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le,
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rabh
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ena,
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itch
ell
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toor
goon
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ck,
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CS,
FAA
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tavo
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lalo
na,
MD
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CS.
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tIn
ns
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nit
yS
chool
olM
edic
ine-
‘Depart
ment
ol
Pedi
atric
Surg
ery,
Car
dina
lG
lnw
nC
hlI&
en’s
Med
ical
Cen
ter
Intr
oduct
ion
Res
ults
eW
hen
prop
erly
sele
cted
,co
mpl
icat
edap
pend
icit
is(a
bsce
ss<a
cm,
sym
ptom
s<s
days
)ca
nbe
man
aged
with
earl
yap
pend
ecto
my
•P
atie
nts
with
nnm
ml
WE
ebe
fore
disc
harg
eca
ngo
hom
ew
itho
utan
tibi
otic
,•
Ade
quat
ecl
inic
aldi
agno
sis
can
decr
ease
the
amou
ntof
preo
pera
tive
Crsc
ans
I.C
ompa
recl
inic
alou
tcom
es2.
Ana
lyze
com
plic
atio
nra
tes
Con
clus
ion
3.A
naly
zeim
agin
gan
dan
tibi
otic
usag
e
•E
stab
lish
men
tof
ane
wm
anag
emen
tpr
otoc
olfo
rco
mpl
icat
edap
pend
icit
isim
prov
esre
sour
ceut
iliz
atio
nw
itho
utaf
fect
ing
Met
hods
shor
t-te
rmou
tcom
es
Stu
dyD
esie
nan
dS
amnl
e•
Ove
rall
com
plic
atio
nra
tes
are
not
sign
ific
antl
ydi
ffer
ent
desp
ite
Prot
ocol
esta
blis
hed
inJu
ly20
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vori
ngea
rly
appe
ndec
tom
y
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toco
l(C
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mpa
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ent
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agem
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ocol
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ndic
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urce
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hout
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ctin
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term
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acti
ce.
Itca
nbe
lead
tofa
tal
outc
omes
ifno
tad
dres
sed.
Cas
eP
rese
nta
tion
and
labs
HPI
:A
33-y
ear-
old
Cau
casi
anw
oman
pres
ente
dw
ith
3w
eeks
ofin
crea
sing
fati
gue,
palp
itat
ions
and
shor
tnes
sof
brea
th.
She
had
rece
ived
2do
ses
ofIV
ferr
ous
carb
oxym
alto
se(F
CM
)on
em
onth
prio
rfo
rir
onde
fici
ency
anem
ia.
PE:
Mus
cle
tender
nes
s(t
high
s).
Lab
s:P
04:
1.5
mg/
dL,
FE(P
04):
21%
,24
-H(P
04)
excr
etio
n:3.
4g,
c-te
rmin
alFG
F-23
leve
ls:
116
RU
/mL
(ref
:44
—21
5R
U/m
L)
--
Fer
rous
Car
boxy
maf
tose
Indu
ced-
Lif
eT
hre
aten
ing
Hy
per
ph
op
shat
uri
cH
yp
op
ho
sph
atem
iaan
dN
orm
alC
-Ter
min
alFG
F-23
ina
You
ngP
atie
nt
____
Geo
rge
Vas
quez
-Rio
sM
D’,
Eric
Man
nM
D’,
Kev
inM
arti
nM
D2,
and
Ada
mM
eran
doM
D1
1.D
ivisi
onof
Gen
eral
Inte
rnal
Med
icin
e,D
epar
tmen
tof
Inte
rnal
Med
icin
e,Sa
int
Loui
sU
nive
rsity
,Sa
int
Loui
s,M
O,
USA
SAIN
TL
OU
IS2.
Div
isio
nof
Nep
hrol
ogy,
Dep
artm
ent
ofIn
tern
alM
edic
ine,
Sain
tLo
uis
Uni
vers
ity,
Sain
tLo
uis,
MO
,U
SAU
NIV
ER
SIT
Y. B
ackg
roun
dFi
glA
-B:
phys
iolo
gica
lef
fect
sof
FGF-
23an
dM
anag
emen
tan
dO
utco
me
puta
tive
role
ofFC
M.
Ref
eren
ce-
iron
indu
ced
hypo
phos
phat
emia
:an
emer
ging
com
plic
atio
n(Z
olie
ret
al,
2017
1
Hvp
erph
osph
atur
icH
ypop
hosp
hate
mia
-
Adi
agno
stic
appro
ach
Non
-FG
F-23
med
iate
d
Hy
per
par
athyro
idis
mD
iure
tics
Fanc
oni
synd
rom
e(g
enet
icvs
.dr
ug-
indu
ced)
S TeIO
00*
Inte
nsiv
ere
pla
cem
ent:
IVphosp
horu
s(9
0m
mol
/L/d
ay)
+
P0
phos
phor
us(3
2m
mol
/L/d
ay)
+
IVca
lcit
riol
(1m
ug/d
ay->
3m
cg/d
ay)
Out
com
e:A
fter
2w
eeks
wit
hhi
ghdo
seca
lcit
riol
,se
rum
P04
leve
lsnorm
aliz
ed.
Tw
om
on
ths
late
r:
Pat
ient
ingo
odhe
alth
wit
ha
seru
mP
04at
4m
g/dL
.a—
,
Non
-FG
F-23
med
iate
d
Auto
som
alD
/Rhypophosh
pat
emic
rick
ets
Tum
orin
duce
dos
teom
alac
ia(T
I0)
Iron
poly
mal
tose
infu
sion
s(e
.g.
FCM
)
Dis
cuss
ion
FCM
isan
emer
ging
caus
eof
seve
re.
tran
sien
thy
poph
osph
atem
ia.
Our
,‘“—
ap,
case
high
ligh
tsth
eim
port
ance
ofa
(jri
-I
phys
iolo
gy-d
rive
nap
proa
chto
ia
e4T
he.a
44tr
eati
nghy
poph
osph
atem
ia.
II
PA
ggre
ssiv
ean
dca
refu
lca
lcit
riol
\1’‘
‘‘
1re
plet
ion
isan
inno
vati
veth
erap
y‘h
’,’ZZ
0th
atca
nbe
used
inth
ese
case
s.
Bac
kgro
und
IIn
vest
igat
ions
IU
nder
stan
ding
C3G
NT
reat
men
tan
do
utc
om
e
Bfly
Cas
ep
rese
nta
tio
n
I00
0Ty
pefl
EU
fw
r.a.n
I
IiF
C3-p
o.e
.eL
I
__
.,n_
e—9-
-iA
j
C3gl
omer
vlon
ephr
itis
(C3G
N)
Lab
s:
isa
rare
cond
itio
nre
late
dto
Her
sCr
was
2.6
mg/
dLan
dhe
rco
mpl
emen
tsy
stem
urin
alys
issh
owed
prot
ein
and
dysr
egul
atio
n.H
ydra
lazi
neha
sbl
ood.
A24
-hur
ine
coll
ecti
onno
tbe
enas
soci
ated
wit
hre
veal
ed1.
2gr
ams
ofpr
otei
n.
C3C
Nbe
fore
.A
utoi
mm
une
wor
kup:
Pos
itiv
ean
ti-h
isto
nean
tibo
dies
,lo
wco
mpl
emen
tC3
and
C4
HP
lA
61ye
ar-o
ldC
auca
sian
leve
ls,
posi
tive
AN
A,
and
high
wom
anpr
esen
ted
wit
hp-
AN
CA
and
c-A
NC
Ati
ters
.H
erw
orse
ning
shor
tnes
sof
brea
th,
seru
mm
embr
ane
atta
ckhe
mat
uria
and
low
erex
trem
ity
com
plex
was
0.52
mg/
Led
ema.
(ref
eren
ce<0
.3m
g/L
).
PMH
:H
TNtr
eate
dw
ith
Ren
alB
iops
y:hy
dral
azin
edu
ring
seve
ral
year
sT
ypic
alC3
neph
ropa
thy
wit
hcr
esce
nts.
lmm
unof
iuor
esce
nce
PE:
BP:
165/
98,
anas
arca
and
was
nega
tive
for
IgA
,1g
Mor
lgG
bila
tera
lcr
ackl
es.
but
was
stro
ngly
posi
tive
for
C3.
b
, Cte
Dm
cJpoJ,,n,
r[W
ecn
.sW
yrw
INeL
at
Ow
‘caB
e,r
c4I.
-fl_
r._
1.o—
. 1— V I.
Ffl
_—
B
FD0
Itec
•—
—
Init
ial
ther
apy
:S
here
ceiv
edpu
lse
ster
oids
and
tran
siti
oned
tom
ycop
heno
late
.H
erre
nal
func
tion
det
erio
rate
dtr
ansi
entl
y.
Adv
ance
dth
erap
y:
plas
ma
exch
ange
(8cy
cles
/2w
eeks
).H
erre
nal
func
tion
rem
aine
dst
eady
wit
ha
crea
tini
neat
1.8
mg/
cR.
Fol
low
up:
At
9m
onth
s,C
4no
rmal
ized
and
C3im
prov
edbu
tw
asst
illlo
w.
AN
CA
and
AN
Are
solv
ed.
How
ever
,sh
est
illex
hibi
ted
anti
-his
tone
anti
bodi
es.
Her
5Cr
impr
oved
to1.
6m
g/dL
Con
clus
ion:
drug
-ind
uced
GN
can
have
anad
vers
eco
urse
and
rapi
dly
prog
ress
toad
vanc
edCK
D.
C3C
Nis
ano
vel
imm
une-
med
iate
ddi
seas
eas
soci
ated
wit
hH
ydra
lazi
ne.
1€
1%
Fig
.1-
Mem
bra
nopro
life
nti
ve
Olo
men
jlonep
hntl
san
dC
a
Glo
mer
ulop
ashy
:R
esol
ving
the
Con
fusi
on-
San
jeev
Set
hiet
al.
2011
Fig.
2-S
higa
toxi
n-as
soci
ated
hen
oly
tic
ucem
icsy
ndro
me:
Cunen
t
mol
ecul
arn
ech
anlu
ns
and
Futu
reth
erap
ies
—K
eir
etxl
.20
12
.AIN
TL
OU
ISI
UN
IVE
liSI
TY
HI
I&K
IMI
SI
ml
KM
AI(H
OC
T
I)li
ke
bhayea
lot
of
itlo
mnato
nab
ou
tm
ynio
dca
ltr
eath
iont,
bek
,it
mak
iga
ded
akei
.2)
Iam
wor
ried
abo
ut
my
‘m
,itg
I3)
Iftt
dm
yte
ifw
Itg
abo
ut
me
oanie
lco
uto
um
eof
my
iNncan
14)1
am
ou
nn
oem
inm
ysu
rgeons
ao
ioly
toli
xm
yw
ound
wit
ha
good
kin
gneon
Sccm
e.
5)
Ihost
endcc
orw
hn
tth
ew
m.•
idw
ola
ckis
ost
orm
yti
cla
ncer
I,m
nvtd
.
fill
ftw
ga
el
sine
nfw
nw
tm
ym
aid
mil
lax
isace
Ilara
pfl
mw
ym
oan
7)1
han
wi
d.a
otw
hatm
yw
aald
jll
bolt
Ste
afl
ara
ckn
tap
-a.
11)1
nan
,ix
isi
lCfinn
my
anaid
im
ini
ret
Ike
tite
rn
tue
afl
‘in
0)1
cmfi
xiti
tiar
wit
hp
on
ble
mi,
çil
onbort
from
skin
neic
iy.
loll
ww
nlto
hio
ww
iial
lily
sikit
liç
Involt
n.
Intl
Ifl
oat,s
t,flV
t,ow
,kxty
mw
.am
liti
Kk.
Res
ults
5)V
/Du,d
aft
cri
kIs
gait
——
—III
it
LlR
tnfl
Ila
rita
rtira.t
hrt.s
i
rdu
id&
.i
Ii
Dis
cuss
ion
Su
mm
ary
Ref
eren
ces
arri
val,
pati
ent
requ
ired
intu
batl
onan
dde
mon
stra
ted
sign
sof
TMA
—su
sd
tio
nPo
st-D
KA
Rei
usd
taU
on
IRA
..asJ
nt
463
NtC
btt
rmin
d‘
•Per
iphe
ral
smea
rsh
owin
gev
iden
ceof
TMA
incl
udin
gsh
isto
cyte
san
dde
crea
sed
plat
elet
s.W
rig
htstan.
Pre
trea
tmen
tAD
AM
TS13
activ
ity40
.7%
1(>
66.8
).
tare
wm
plk
Bdin
the
ped
.-th
rOm
b
II
h3O
KA
r
flth
ese
t dn&
flen
sion
was
tera
)hem
orr
lr
Hi4
rflvfli
nea
r-no1
-
ipabent
Wa
and
seps
is,b
mñ
ad
uft
pf
Att
hoult
AD
lo
ur
p?i
fle3
espo
norm
ati z
atlo
noH
As
rnport
eac
t.an
d
cth
rom
bocy
tope
nic
purp
um(F
TP)
was
susp
ecte
d,
an
leve
lw
asob
tain
ed,
and
TPE
was
init
iate
d(1
0pl
asm
a
FFP
repl
acem
ent
usin
gth
eS
pect
raO
ptia
‘u
mO
BC
take
woo
d,CC
))..,
utk
reco
very
Inpla
tele
tco
unt
and
Inca
ioi
—S
e—
‘ym
oder
ate
wft
ha
—+
Esm
ay
Che
mot
hera
pyan
dst
emce
lltr
ansp
lant
atio
nar
eas
soci
ated
with
anin
crea
sed
inci
denc
eof
fung
alin
fect
ions
inpa
tien
tsw
ith
hem
atop
olet
icm
alig
nanc
ies.
The
risk
offu
ngal
infe
ctio
nsis
furt
her
com
poun
ded
byde
laye
den
graf
tmen
t,w
hen
umbi
lical
cord
bloo
dce
llsar
eus
edas
ast
emce
llSo
urce
.W
ere
port
the
succ
essf
ulus
eof
gn
nu
locy
tetr
ansf
usio
n(G
m),
asa
prop
hyla
ctic
mea
sure
,in
ape
diat
ric
pati
ent
wit
hse
vere
apla
stic
anem
iaan
dpr
evio
usin
vasi
vefu
ngal
infe
ctio
nw
houn
derw
ent
doub
leum
bilic
alca
rdbl
ood
(DU
G)
tran
spla
nt.
Dur
ing
pre-
tran
spla
ntev
alua
tion
,a
ches
ta
show
eda
righ
tup
per
lobe
cavi
tary
lesi
onco
ncer
ning
for
fung
alin
fect
ion.
Ant
ifun
gal
ther
apy
was
star
ted
and
thor
asco
pic
surg
ery
wit
hw
edge
rese
ctio
nre
veal
edin
vasi
veas
perg
illo
sis.
With
near
-res
olut
ion
ofhe
rcl
inic
alsy
mpt
oms
and
stab
leim
agin
g,a
DU
CS
tran
spla
ntw
asin
itia
ted.
Due
toa
high
risk
for
recu
rren
ceof
inva
sive
aspe
rgil
losi
sbe
fore
engr
aftm
ent,
5pr
ophy
lact
icG
TXw
ere
prov
ided
duri
ngth
efi
rst
two
wee
ksof
the
DU
Gtr
ansp
lant
star
ting
ontr
ansp
lant
day
2.
C-7
Hig
hgr
anul
ocyt
eyi
elds
wer
eac
hiev
edw
ithdo
nor
stim
ulat
ion
(0-
CSF
and
dexa
met
haso
ne).
Due
toth
epa
tient
’ssi
ze,r
educ
edvo
lum
ew
asco
llect
edan
d
tran
sfus
ed.
The
pati
ent
rece
ived
asi
ngle
6Th
infu
sion
ontr
ansp
lant
days
2,5,
7,9,
and
13an
dre
spon
ded
favo
rabl
y(A
NC
>500
).
The
pati
ent
achi
eved
WBC
engr
aftm
ent
AN
C>
5)
ontr
ansp
lant
day
14.
The
pati
ent
had
noev
iden
ceof
recr
udes
cent
aspe
rgill
osis
.
An
S-ye
arol
dgi
rlw
astr
ansf
erre
dfr
oman
outs
ide
hosp
ital
for
emes
is,
head
ache
,ex
erti
onal
dysp
nea,
and
fati
gue.
No
evid
ence
ofly
mph
aden
opat
hyor
sple
nom
egal
y
Panc
ytop
enla
:H
emog
lobi
n1.
5g/
dL(1
0.6-
13.4
)Pl
atel
ets
6x
10’/i
iL(1
99-2
69)
woc
0.1
xlO
’fpc
(45-
13.5
)
Mar
kedl
yhy
poce
llut
arbo
nem
arro
ww
itho
utev
iden
ceof
mal
igna
ncy
Infe
ctio
uset
iolo
gies
, inh
erite
dbo
nem
arro
wfa
ilure
synd
rom
es,p
arox
ysm
alno
ctur
nal
hem
oglo
binu
ria
IDIO
PATh
ICSE
VER
EA
PLA
STIC
AN
EMIA
---
Don
oran
dP
atie
ntL
abor
ator
yY
ield
s
Gm
Don
orD
onor
Prod
uct
Patie
ntPr
eW
OC
Post
WB
CW
OC
WB
Cx1
03/p
Lxl&
/pL
x102
/IsL
a103
/p(.
21.6
910
6.83
0.1
4899
235.
58D
.3
21.6
467
.11
2.0
rsI1
JtI
ffl:
TL
MJtW
thII
[.]i
C...
Phys
ical
Exam
Pedp
hera
lSm
ear:
CRC
Bon
eM
arro
w
Dis
ease
sEx
clud
ed
Fina
lD
iagn
osis
14
24
2
Pre
ANC
Post
AN
Cx1
03/I
Iix1
03/p
L
3-55
3
The
rape
utic
gran
uloc
yte
yiel
dsca
nbe
obta
ined
by
9,13
Th.
0390
.91
0.1
<20
0
4
aphe
resi
sw
ithap
prop
riat
edo
nor
stim
ulat
ion.
1,20
0
4.57
<20
0
This
case
dem
onst
rate
sth
atG
TXs
may
be
1,28
7
<20
0
bene
fici
alin
prev
enti
ngre
curr
ent,
life
-thr
eate
ning
5,00
0
fun
gal
infe
ctio
nsin
pedi
atri
ctr
ansp
lantp
atie
nts
1,96
01,
152
inth
ese
ttin
gof
seve
reim
mun
osup
pres
sion
befo
reW
BC
eng
raft
men
t
56.
9345
.63
226.
920.
655
84,
224
S
SAIN
TL
OU
ISU
NIV
ER
SIT
Y-
—E
S!.
•S
i—
Idea
How
dow
ehe
lpno
vice
gast
roen
tero
logi
sts
reco
gniz
eG
Iem
erg
enci
es?
__
__
__
katio
naie
Rec
ogni
zing
emer
genc
ies
isth
efi
rst
and
the
mos
tvi
tal
step
toin
itiat
eth
ehi
gher
leve
lof
care
requ
ired
inth
ese
tim
ese
nsit
ive
situ
atio
ns.
How
doyo
ute
ach
new
trai
nees
tobe
awar
eof
thei
rlim
itatio
ns,
toas
kfo
rhe
lp,
and
tore
cogn
ize
wha
tth
eydo
n’t
know
?
[eth
ods
An
inte
ract
ive
lect
ure
was
prov
ided
tofi
rst
year
fell
ows
inth
efi
rst
seve
ral
wee
ksof
fell
owsh
ip,
stre
ssin
gav
aila
bilit
yof
seni
orle
arne
rsan
dfa
cult
ysu
ppor
t.•
Abr
ief
pre-
test
and
post
-tes
tw
ere
dist
ribu
ted.
Afo
llow
upte
stan
dop
enfo
rum
wer
epr
ovid
ed4
wee
ksaf
ter
the
initi
alle
ctur
e.
Ex
amp
les
ofT
opic
sU
pper
GI
Acu
teC
om
pli
cati
ons
blee
ding
colo
nic
ofen
do
sco
py
(non
-p
seu
do
var
icea
l)obst
ruct
ion
Low
erG
IA
cute
Acu
tebl
eedi
ngch
ola
ngit
isp
ancr
eati
tis
Var
icea
lA
cute
For
eign
body
ble
edin
gsc
hem
iain
ges
tion
Sig
moi
dA
cute
live
rF
ood
volv
ulus
fail
ure
impa
ctio
n
85%
iiI
[u
lft
___
1
•29
%im
prov
emen
tin
pre
and
post
-tes
tsc
ore
aver
ages
(66%
[ran
ge55
to82
%]
vs95
%[r
ange
91to
100%
})•
Re-
test
scor
eav
erag
esre
mai
ned
impr
oved
(86%
,ra
nge
82to
91%
)fr
omin
itial
asse
ssm
ent.
•A
llof
the
trai
nees
repo
rted
that
the
lect
ure
was
help
ful
and
that
they
wou
ldbe
inte
rest
edin
help
ing
prep
are
new
trai
nees
for
Cl
emer
genc
ies
next
year
.
—c’?t
Dis
cuss
ion
•O
urgo
alw
asto
prov
ide
aco
ncis
ean
dre
leva
ntro
adm
apfo
rno
vice
trai
nees
toid
entif
y“C
lem
erge
ncie
s”an
dto
emph
asiz
eth
eso
cial
stru
ctur
eav
aila
ble
tosu
ppor
tth
em.
•In
the
futu
re,
we
will
wor
kto
pre
sent
Cl
emer
genc
ies
ina
mor
eac
tive
lear
ning
bas
edcu
rric
ulum
asth
isha
sbe
enfo
und
tobe
mor
een
gagi
ngan
dto
impr
ove
tran
smis
sion
ofm
ater
ial.
Concl
usi
on
An
inte
ract
ive
lect
ure
impr
oved
novi
cetr
aine
ekn
owle
dge
ofC
lem
erge
ncie
san
dsu
ppor
tst
ruct
ure.
The
acqu
isit
ion
ofkn
owle
dge
was
show
nto
bedu
rabl
e.F
utur
ere
sear
chw
illfo
cus
onm
easu
ring
chan
ges
rega
rdin
gfe
llow
effi
cien
cyn
dpa
tien
t_ou
tcom
es.
-
Pre
pari
ngG
astr
oent
erol
ogy
Fel
low
sfo
rE
mer
genc
ies
Mec
huM
eyN
aray
anan
,M
Dan
dE
liza
bet
hM
arsi
cano,
MD
Sai
ntL
ouis
Uni
vers
ilyH
ospi
tal
Aver
age
Sco
res
95%
Imag
esfr
omin
tera
ctiv
ele
ctur
e
Ref
emnce
sI
Ada
ms,
MA
,G
ray
OM
.,R
etw
aroo
,G
&N
avig
atin
ga
Suc
cess
ful
cour
seth
roug
hG
IF
ello
wsh
ip:A
vear
-by-
Yea
rP
ersp
ecti
ve.
Gas
troe
nter
otog
y.20
14Ja
nuar
y;14
6(l)
:5-9
.
2.In
raJ.
A,
Pelle
lier
3,K
umar
NL
.B
arne
sE
Lan
dS
hiel
dsN
M.
An
acti
vele
arni
ngcu
rric
ulum
impr
oves
fello
ws
know
ledg
ean
dfa
culty
teac
hing
skill
s.A
dvan
ces
inM
edic
alE
duca
tion
and
Pra
ctic
e.20
17M
ay;
8:35
9-36
4
0
SA
INT
LO
UIS
UN
IVER
SIT
Y—
IS?.
liii
-
j-:
:rT
Idea
__________________
Wou
lda
case
bas
edle
arni
ngfo
rmat
beef
fect
ive
inte
achi
ngin
tern
alm
edic
ine
resi
dent
sth
eke
yco
ncep
tsin
eval
uati
ngel
evat
edliv
erch
emis
trie
s?
Rat
Iona
leE
--7
Tra
diti
onal
lect
ure
bas
edte
achi
ngpl
aces
stud
ents
ina
pass
ive
role
;ac
tive
lear
ning
ism
ore
enga
ging
,an
din
cert
ain
stud
ies
show
nto
impr
ove
know
ledg
eac
quis
itio
n(I
nra
2017
,T
hist
leth
wai
te20
12).
•C
ase
bas
edle
arni
ngis
anex
ampl
eof
acti
vele
arni
ng•
We
pres
ent
the
eval
uati
onof
liver
chem
istr
ies
inan
inte
ract
ive
lear
ning
envi
ronm
ent.
NA
SHci
rrhosi
s
Acu
teliv
erfa
ilure
:.ef.
kA
lcoh
olic
hepa
titi
st-
.;&
J•ss$
Cas
esdis
cuss
ed
IIil;z
il1O
da:.
•C
ase
bas
edle
arni
ngse
ssio
ns
with
abou
t15
resi
dent
sdi
scus
sing
2-3
hepa
tolo
gyca
ses.
•E
ach
case
had
ase
tof
ques
tion
sfo
cuse
don
diag
nosi
san
dcl
inic
alm
anag
emen
t.•
Par
tici
pant
sw
ere
give
na
hand
out
revi
ewin
gm
ajor
conc
epts
.•
Wri
tten
feed
back
was
obta
ined
with
surv
eys.
tResu
ift
•T
hem
ajor
ityof
the
resi
dent
sw
hore
turn
edsu
rvey
sw
ere
seni
orre
side
nts;
surv
eyre
turn
rate
was
73%
.•
All
ofth
ele
arne
rsra
ted
the
case
dbas
edle
arni
ngfo
rmat
tobe
abe
tter
expe
rien
ceth
anst
anda
rdle
ctur
es.
•A
llpa
rtic
ipan
tssa
idth
eyw
ould
like
todi
scus
sm
ore
hepa
tolo
gyca
ses
inth
isfo
rmat
.•
Man
ypa
rtic
ipan
tslik
edth
ein
tera
ctiv
ena
ture
ofth
ese
ssio
n.
Ove
rall
experi
ence
Eng
agin
g
Use
ful 4.
44
64.
85
Lik
edS
cale
Co
ncl
usi
on
•T
each
ing
Hep
atol
ogy
ina
case
bas
edfo
rmat
impr
oved
lear
ners
enga
gem
ent.
•C
ase
bas
edle
arni
ngin
corp
orat
es“d
esir
able
diff
icul
ties
”in
toth
ele
arni
ngex
peri
ence
whi
chha
sbe
ensh
own
toim
prov
etr
ansf
erof
info
rmat
ion
and
“lon
g-te
rmre
tent
ion”
(Bjo
rk20
06).
•T
his
pilo
tst
udy
prov
ided
proo
fof
conc
ept
for
impr
oved
lear
ning
usin
gca
sed
bas
edle
arni
ng.
Fut
ure
stud
ies
will
focu
son
asse
ssm
ent
ofco
mfo
rt,
know
ledg
eac
quis
itio
nas
wel
las
rete
ntio
n,an
ddi
ffer
ent
lear
ners
(suc
has
med
ical
stud
ents
).
I.fij
ork
RA
,an
dI_
inn
MC
.T
heS
cien
ceof
Lea
rnin
gan
dth
eL
earn
ing
ofS
cien
ce:
Intr
oduc
ing
Des
irab
leD
iffic
ultie
s,O
bser
ver
2006
Mar
ch;
19(3
).2.
Inra
JA.
Pel
leti
erS
,K
urna
rN
L,fl
ames
EL
and
Shi
elds
HM
.An
activ
ele
arni
ng
curr
icul
umim
prov
esfe
llow
s’kn
owle
dge
and
facu
ltyle
achi
ngsk
ills.
Adv
ance
sin
Med
icat
Edu
catio
nan
dP
ract
ice,
2017
May
;8:
359-
364.
3.T
hist
leth
wai
teJ,
E..
Dav
ies
0.
Eke
ocha
S.,
Kid
dJ.
M.,
Mac
ooug
all
C.,
Mat
thew
sP.
,C
lay
D.
(201
2).
The
effe
ctiv
enes
sof
case
-bas
edle
arni
ngin
heal
thpr
ofes
sion
aled
ucat
ion.
AB
EM
Esy
stem
atic
revi
ew:
BEM
EG
uide
No
23.
Med
ical
Tea
cher
,34
(6),
e421
—e4
44.
Fro
rnth
eA
CG
guid
elin
es
Tea
chin
gH
epat
olog
yU
sing
Cas
eM
ech
uM
eyN
aray
anan
,
Bas
edL
earn
ing
MD
,Sc
ott
Hol
mes
,D
Oan
dch
arle
nePr
athe
r,M
D,M
PHS
aint
Lou
isU
nive
rsit
yH
ospi
tal
()
Sur
vey
Fee
dbac
k
App
roac
hto
elev
ated
liver
chem
istr
iest
SS
App
roac
hto
elev
ated
liver
chem
istr
ies*
S
S
Ref
eren
ces
Ep
idem
iolo
gy
ofH
osp
ital
ized
IBD
pat
ients
wit
hA
sth
ma
IN
.,
An
aly
sis
ofth
eN
atio
nal
Inpat
ient
Sam
ple
SAIN
TLO
UIS
Muh
amm
adH
amm
ami,
MD
3,G
ebra
nW
.K
hnei
zer,
MD
2.A
hmad
Al-
The
e.M
D2,
Kah
eeA
.M
oham
med
.M
D!
MPH
2.C
hri
stin
eH
ache
m,
MD
1U
NIV
ER
Sr
Q,v
is,o
41o
fG
asI
.c2
”:e
rcIo
r,,
and
Hep
atolo
gy
‘Depart
ment
of
Inte
rnal
lieu
u’‘&
S.
‘‘
L:,.“-.‘iIy
Sch
ool
of‘.
‘:-:
:‘e
SI
Louis
.’’
Bac
kgro
und
and
Aim
•Th
ein
cide
nce
ofIB
Dan
das
thm
ain
the
Uni
ted
Stat
esha
vebe
enin
crea
sing
over
(he
past
deca
de.
-Bo
thco
nditi
ons
aris
efo
rma
com
plex
inte
ract
ion
betw
een
gene
tican
den
viro
nmen
tal
fact
ors.
•Th
isst
udy
aim
sat
I.ex
plor
ing
the
epid
em:o
logy
and
outc
omes
ofho
spita
lized
IBD
patie
nts
with
asth
ma,
and
2.co
mpa
ring
the
abov
efin
ding
sw
ithho
spita
lized
asth
ma
patie
nts.
Ow
n))
Wit
hout
545t
hA
sthm
aA
sthm
a1,
712,
160
1,63
0,93
1192
114
1230
(8)
pva
lue
30.5
41.5
24
5693
51.5
3
oA
r:’,
:,’
Fla
ils
-
Met
hods
31.4
33.1
29.4
80
21
03
8552
3.9
Cha
raci
eris
i,,s
Num
ber
ofp
atie
nts
.N
fWe,
ghle
dI
Sea M
ale
Fem
ale
Age
(yn
I‘4
14
56
4ca
bs
Rac
e/et
hn,n
tyV
erne
mad
Ibspn
teg
,on
Nort
hea
stM
idw
est
Wes
tS
ou
th90
subty
pe
uc
CD
Ilin
haus
reco
me,
b,di
lyIn
de,
Co
CI
(2 (3
34.9
13
30.1
3775
1.9
74.1
6.1
93
‘.1
50.
5
36
0.3
Ass
ocia
t,tt
betw
een
Ast
hma
Ota
ncom
esa
!stb
l,’
and
in’h
osp,
Iai
Mona]
,ty
aed
pro
torg
ed’
hosp
,tal
iaat
,un
I.U
tiliz
ing
2008
-201
3N
atio
nwid
eIn
patie
ntSa
mpl
e,w
eid
entif
ied
30g,
686
hosp
italiz
edIB
Dpa
tient
sus
ing
ICD
-9co
des.
We
used
wei
ghte
dm
ultiv
adat
elo
gisli
cre
gres
sion
mod
els
to:
1.ex
amin
eth
eso
ciod
emog
raph
ican
ddi
nica
lch
arac
teri
stic
sof
asth
mat
icIB
Upa
tient
s,an
d2.
eval
uate
the
impa
ctof
anas
thm
adi
agno
sis
onth
ele
ngth
ofst
ayan
din
-hos
pita
lmor
talit
y.
DR
(95
%O
PP
sait
e0.
4910
.430
.561
<.1
0.72
(a.6
9—
0.14
1c.1
Tab
lel
(ha,
a,:a
,‘u
s
Set M
a
Fem
ale
Age
yr.)
‘45
45
64
a‘6
5
B’a
,i. par
,,
Oth
e’
i’fl
‘actS
,’,
Jeen..
’cU
wes
t
Sou
th
Cin
hac
ce,
‘tn’s
’b’
thty
Co Cl
[7 Cl
22.5
705
225
.623
.422
15.4
15.1
3.4
35
533
z.5
36.6
33.9
2.7
35.4
51.1
5.4
05
8(t
.56.0
.6)
l.6
]lle
fere
nce
l
1.
Ref
eren
ce)
0.6
4(6
66
’li
t)0
31
(5IS
.0.3
9)
1,2
4(1
19
—1.
29)
1.1
20
11
.1.
25)
1.02
10.94
—10
9)
3m
IRef
eerr
al
15
4(1
48—
059
)
1.32
(I23
—1.
36)
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11.3
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ereo
ce)
Ref
eren
ce)
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(15
69—
2’2t
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3351
(21
12—
359
2)
6333
S4Si
—
29Sa
l
Tae
3:Im
.hU
SpIa
ini
odat
ilyan
dLe
ngth
ofS
lay.
?
lay
ntp
dr
,dew
Ii
t0.li
2738
pItI
de
069
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145
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228
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71.1
19.3
37.6
32.7
<re
in
cex
I
Con
clus
ions
0.t 1,3
1.14 4.9
•H
ospi
taliz
edas
thm
atic
IBD
patie
nts
are
mor
elik
ely
tobe
ofag
e<4
5,fe
mal
e,of
Afri
can
Am
eric
anor
His
pani
cet
hnic
ityan
dha
vea
shor
ter
hosp
ital
stay
&lo
wer
in-h
ospi
tal
mor
talit
y.T
hese
findi
ngs
can
beut
ilize
dto
risk
stra
tify
and
toin
dMdu
aize
care
fora
high
erris
kIB
Upa
tient
popu
latio
n
Hig
her
pu
rpo
se.
Gre
arer
good:
Case
A50
year
old
Cau
casi
anw
oman
with
ahi
stor
yof
asth
ma
pres
ente
dw
ithsu
dden
onse
tan
teri
orch
est
pain
and
dysp
nea
seve
ral
days
afte
rth
eon
set
ofdu
inor
rhea
,dr
yco
ugh,
and
sore
thro
at.
Pai
nim
prov
edw
ithle
anin
gfo
rwar
d.
Anx
ious
;sh
allo
wbre
aths;
dear
lung
liel
ds;
tad9yrd
ic;
no
LE
edem
a
•E
KG
9sI
nu
sta
chyca
rd,a
•0-d
iner
426
4ti
N.
23O
ngIm
L)
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ropo
nin,
ceo,
cup
9fl
IiL
Ord
ered
CTP
6p
roto
col
moder
ate
pencara
lef
fusi
on,
bla
tero
lW
arad
enath
y.
noP
c
•In
fedi
ous
etio
logy
4b
aden
al,
vira
l,T
hst
ains,
wk
ises.
sero
logie
siv
igate
e
•R
heum
etio
logy
-I•
saee
nm
gA
MA
lCO
nMm
aIaY
Men
r.egabbt)
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lR
heL
aIl
pie
ln
eg
ati
ve
•EB
uSei
lhbi
opsy
flow
cyto
mel
ry9
nom
alig
nan
cy•
PE
T-C
T4
no
n-s
ped
tcFO
Gav
idm
ed’a
sUna
lLN
-V
iral
Per
icar
diti
sT
o:ib
upro
fen
+co
thic
ine4
sym
ptom
sre
solv
edD
Con
hosp
itat
day
5
RE
FER
EN
CE
SI.
wre
ns,
Mel
xi.
tain
,eni
13.0
555.M
aia
pir
rediP
andi
Cease
Csn
si*
n20
10.1
2111
6-52
1.N
taJR
flsw
igII
otcl
Rcu
Lel
oFL
ea&
lors
wsa
teO
eLI
,ii.
Aor
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led
04
mw
e1
teix
inb
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r*bra
ia,e
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ialv
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ousr
yr.5
4’
11.1
61.
201k
2111
111
1117
.112
4.1
Ad
.y,o
vrP
,te
laA
.eiC
1O
i5E
sC&
akvse
Ce7rn
lMa1agerw
oli
Peyad4
Cea,
eir
ika’
IJ2O
lSfi
te29
.
•A
boul
B0%
ofpe
rica
rditi
sca
ses
inth
ede
velo
ped
wor
ldar
eid
iopa
thIc
.O
ther
etio
logi
esin
clud
ene
opta
stic
.in
fect
ious
,an
dau
faim
mun
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