Adhesive Small Bowel Obstruction in Children andAdolescents: Operative Utilization and FactorsAssociated with Bowel LossTimothy B Lautz, MD, Mehul V Raval, MD, Marleta Reynolds, MD, FACS, Katherine A Barsness, MD, FACS

BACKGROUND: Adhesive small bowel obstruction (ASBO) develops in �5% of children and adolescents aftermajor abdominal surgery. The aims of this study were to: 1) describe the current use of operativemanagement in children and adolescents with ASBO and 2) investigate the association betweenoperative delay and the rate of small bowel resection.

STUDY DESIGN: All patients 2 to 20 years of age admitted with ASBO in the 2003 and 2006 Kids’ InpatientDatabase (KID) were identified. Rates of operative intervention were described, and factorsassociated with small bowel resection were analyzed in a logistic regression model.

RESULTS: Of 2,089 patients admitted with ASBO, 1,786 (85.5%) underwent operative intervention withlysis of adhesions (LOA; n � 1,493; 83.6%) or small bowel resection (SBR; n � 293; 16.4%).Factors associated with the use of operative intervention in univariate analysis included youngerage (p � 0.001), race (p � 0.034), and management at a children’s hospital (p � 0.001). Thetime from admission until operation (mean � SD) was significantly longer in patients whounderwent SBR (2.1 � 2.6 days) compared with LOA (1.5 � 2.0 days; p � 0.001). Comparedwith patients who underwent surgery within the first day after admission, the adjusted odds ofSBR were similar on the second day after admission (odds ratio [OR] 1.40, 95% confidenceinterval [CI] 0.94 to 2.09) but increased when surgery was performed on days 3–14 (OR 1.67,95% CI 1.19 to 2.34).

CONCLUSIONS: The majority of children and adolescents admitted with ASBO currently undergo operativemanagement, and 16.4% of these patients receive small bowel resections. Operative interven-tion should be considered in patients who do not exhibit signs of improvement by the secondday after admission to avoid potentially increasing the risk for bowel loss. ( J Am Coll Surg 2011;

212:855–861. © 2011 by the American College of Surgeons)

Adhesive small bowel obstruction (ASBO) is associatedwith long-term morbidity after abdominal operations inboth children and adults. ASBO occurs in 1% to 6% ofchildren after abdominal surgery, and the rate is dependenton the initial type of operation.1-4 The optimal manage-ment of ASBO in the pediatric population is debated.5,6

An initial trial of nonoperative management has becomestandard practice for most adults with ASBO. Early oper-ative intervention is mandated for patients who presentwith signs and symptoms concerning for strangulation. Inthe remaining patients, successful resolution of the ob-

Disclosure Information: Nothing to disclose.

Received October 8, 2010; Revised January 11, 2011; Accepted January 11,2011.From the Department of Surgery, Children’s Memorial Hospital, Northwest-ern University, Chicago IL.Correspondence address: Katherine Barsness, MD, Children’s Memorial

Hospital, 2300 Children’s Plaza, Box 63, Chicago, IL 60614. email:Kbarsness@childrensmemorial.org

855© 2011 by the American College of SurgeonsPublished by Elsevier Inc.

struction with nonoperative management has been re-ported in 43% to 64% of adults.7-9 However, the safety andefficacy of conservative management remains largely un-proven in the pediatric and adolescent populations. Thereported success of nonoperative management varieswidely, from 16% to 63%.5,6,10 The relatively high rate ofoperation may partially reflect unease with protracted trialsof conservative management among pediatric surgeons.Reports also differ on whether delaying surgery increasesthe risk of complications, including bowel resection.5,6 Abetter understanding of the association between surgicaldelay and the risk of bowel resection is needed to guiderecommendations for the management of ASBO in chil-dren and adolescents.

The purpose of the present study was twofold: 1) todescribe current management of children and adolescentswith ASBO; and 2) to identify factors associated with in-creased rates of small bowel resection by using a nationally

representative administrative dataset.

ISSN 1072-7515/11/$36.00doi:10.1016/j.jamcollsurg.2011.01.061

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METHODSDatasetData on US children and adolescents admitted with a pri-mary diagnosis of ASBO in the years 2003 and 2006 wereobtained from the Agency for Healthcare Research andQuality–sponsored Healthcare Cost and Utilization Proj-ect Kids’ Inpatient Database (KID). The KID is an admin-istrative dataset of patients aged �20 years and currentlycontains data on �10 million hospitalizations from 38tates. Versions of the KID are released in 3-year cycles andhe 2 most recent release dates were used in the presenttudy. The KID samples 10% of routine births and 80% ofediatric cases from each hospital. KID is estimated toapture 87% of the US pediatric population.11 Discrete

(unweighted) cases from the KID were used in the presentanalysis.

Inclusion and exclusion criteriaPatients admitted with a primary diagnosis of ASBO wereidentified using the International Classification of Disease,9th Revision, Clinical Modification (ICD-9-CM) code560.81. Additionally, patients with a primary diagnosis ofabdominal pain (789.0), emesis (787.01 to 787.03), ordehydration (276.51 to 276.52) and a second diagnosis ofASBO were included. To ensure that patients with other(non-ASBO) etiologies of obstruction were not errone-ously included in the analysis, all diagnosis and procedurefields were searched for ICD-9 codes indicative of incarcer-ated hernia (550.0 to 550.1, 551 to 552), Meckel divertic-ulum (751.0), intestinal duplication (751.5), intussuscep-tion (560.0), and malrotation requiring Ladd procedure(54.95). Patients with any of these alternative causes ofobstruction were excluded from analysis. Patients withmalrotation were only excluded from analysis if they un-derwent Ladd procedure during this hospitalization. Oth-erwise, they were presumed to have an ASBO related to anearlier operation for their disease. Patients with large intes-tine pathology requiring colon resection (45.7 to 45.8)

Abbreviations and Acronyms

ASBO � adhesive small bowel obstructionCI � confidence intervalICD-9-CM � International Classification of Disease, 9th

Revision, Clinical ModificationKID � Kids’ Inpatient DatabaseLOA � lysis of adhesionsLOS � length of stayOR � odds ratioSBR � small bowel resection

were also excluded. a

Additional patient exclusions were based on patient ageand features of the hospitalization. Analysis was limited topatients 2–20 years of age. A small number (n � 28) of

atients who remained hospitalized beyond 14 days afterdmission without undergoing an operation were deemedo be irregular and excluded. These patients were consid-red to have atypical extenuating circumstances that couldot be ascertained and properly accounted for using thevailable administrative data.

Variables and outcomesThe percentage of patients with ASBO requiring operativeintervention was determined by searching for procedurecodes for lysis of adhesions (LOA; ICD-9 54.11, 54.21, or54.5) or small bowel resection (SBR; ICD-9 45.61 to45.63). Patient- and hospital-specific characteristics werecompared between patients who underwent nonoperativemanagement and those requiring operative intervention(LOA or SBR). These characteristics included age, sex,race, primary insurance, and hospital type (children’s ornonchildren’s). Age was classified into 4 groups of approx-imately equal size (2–7, 8–14, 15–18, and 19–20 years).Race and ethnicity were classified as white, black, Hispanic,and other/unknown. Primary insurance was classified asMedicaid, private insurance, or other/unknown. The KIDassigns each hospital to 1 of 4 center types based on Na-tional Association of Children’s Hospitals and Related In-stitutions designation: freestanding children’s hospital,children’s specialty hospital, children’s units within generalhospitals, or general/nonchildren’s hospitals.12 All chil-

ren’s hospitals and units were compared with general/onchildren’s hospitals.The need for SBR was used as the primary outcome.

atients with procedure codes for both LOA and SBR werencluded in the SBR group. The rate of SBR was asse-sed as a fraction of all patients who remained “at risk” afterach day of nonoperative management, ie, the number ofatients who remained hospitalized without having under-one an operation. The analysis was designed to address thelinical question about whether additional days of nonop-rative management increase the likelihood that a patientill require a bowel resection during the hospitalization.atients who underwent operative intervention on an un-nown hospital day were excluded from the analysis.

The subset of patients who underwent operative inter-ention was then analyzed to determine factors associatedith an increased rate of SBR. The time from admissionntil operation was again investigated. Additional factorstudied included patient age, sex, race, primary insurance,

nd hospital type.

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This study was conducted under exempt status after re-view of study protocols by the Northwestern UniversityInstitutional Review Board.

Statistical analysesContinuous variables were reported as mean � standarddeviation unless otherwise stated. Preliminary inferentialstatistics were calculated for all variables using chi squaretests for categoric data and Student t test for continuous

ata. All analyses were 2 tailed, and statistical significanceas defined as p � 0.05.A logistic regression model was constructed, and all fac-

ors of clinical importance were forced into the model. Allatient and hospital data were not available for all cases. Forach patient or hospital factor other than sex, cases withissing data were categorized as “unknown” in both the

nivariate analysis and regression model. Logistic regres-ion model discrimination and calibration were asse-sed using the c-statistic and Hosmer-Lemeshow (H-L)oodness-of-fit, respectively. A higher c-statistic indicateshat the model is superior at discriminating patients whoxperience the event of interest from those who do not (0.5ndicates that the model is equivalent to chance, 1.0 that

Table 1. Patient and Hospital Characteristics of Children andOperative or Conservative Management

All(n � 2,089)

Age, y (mean � SD) 12.6 � 5.8Age group, y, n (%)

2–7 537 (25.7)8–14 568 (27.2)15–18 597 (28.6)19–20 387 (18.5)

Sex, n (%)*Male 1,312 (63.9)Female 740 (36.1)

Race/ethnicity, n (%)White 815 (39.0)Black 233 (11.2)Hispanic 314 (15.0)Other/unknown 727 (34.8)

Primary insurance, n (%)Private 1,130 (54.1)Medicaid 708 (33.9)Other/unknown 251 (12.0)

Hospital type, n (%)Children’s hospital 941 (45.0)Nonchildren’s hospital 1,031 (49.4)Unknown 117 (5.6)

*37 patients with missing sex were excluded.

he model has perfect discrimination). A nonsignificant p

alue for the H-L test indicates a well calibrated model inhich the observed and expected event rates are similar. Allata manipulation and statistical analyses were performedsing SPSS, version 18 (SPSS Corp, Chicago, IL).

RESULTSThere were 2,320 pediatric and adolescent (aged 2–20)admissions in the 2003 and 2006 KIDs with a diagnosis ofASBO. Subsequently, 203 patients were excluded becauseof a concurrent diagnosis of incarcerated hernia, intussus-ception, Meckel diverticulum, or intestinal duplication ora procedure code for colon resection or Ladd procedure. Anadditional 28 patients who remained hospitalized beyond14 days after admission without undergoing an operationwere deemed to be irregular and were excluded. This left2,089 patients included in the primary analysis. ASBO wasmore common in boys (63.9%). The mean age was 12.6 �.8 years. The mean length of stay (LOS) was 8.0 � 6.4

days, and in-hospital mortality occurred in 12 patients(0.6%).

Operative intervention was performed in 1,786 (85.5%)of the 2,089 patients, including LOA in 1,493 (83.6% of

lescents with Adhesive Small Bowel Obstruction Undergoing

Operative(n � 1,786)

Conservative(n � 303) p Value

12.3 � 5.8 14.5 � 5.0 �0.001�0.001

495 (27.7) 42 (13.9)492 (27.5) 76 (25.1)490 (27.4) 107 (35.3)309 (17.3) 78 (25.7)

0.841125 (63.8) 187 (64.5)637 (36.2) 103 (35.5)

0.034691 (38.7) 124 (40.9)211 (11.8) 22 (7.3)276 (15.5) 38 (12.5)608 (34.0) 119 (39.3)

0.09949 (53.1) 181 (59.7)620 (34.7) 88 (29.0)217 (12.2) 34 (11.2)

�0.001859 (48.1) 82 (27.1)819 (45.9) 212 (70.0)108 (6.0) 9 (3.0)

Ado

operative cases) and SBR in 293 (16.4%).Table 1 compares

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patient and hospital characteristics among patients man-aged operatively and nonoperatively. Factors associatedwith operative intervention in univariate analysis includedyounger age (p � 0.001), race (p � 0.034), and manage-ment at a children’s hospital (p � 0.001). Patient sex andprimary insurance were not associated with operativeintervention.

The rate of SBR among “at-risk” patients after each dayof nonoperative management is shown in Fig 1. All patientswho remained hospitalized without having undergone anoperation on each day were categorized as “at risk.” Threehundred forty-three of the 1,786 patients managed surgi-cally were excluded from this analysis, because they lackeddata on the time from admission until operation. The rateof SBR was similar among the operative patients who wereincluded (16.2%) and excluded (17.2%; p � 0.66). All03 patients managed nonoperatively were included in thisnalysis. Overall, 234 (13.4%) of the 1,746 at-risk patientsncluded in this analysis underwent SBR at some pointuring their admission. Patients who remained at risk 1n � 1,185) or 2 (n � 759) days after admission had3.9% and 14.0% rates of SBR during their subsequent

Figure 1. Subsequent rate of small bowel resection (SBR) aftereach day of nonoperative management. The rate of SBR as afraction of “at-risk” patients on each hospital day is shown graphi-cally, and numerator and denominator data are shown in the table.For each hospital day, the “at-risk” population includes all patientswho remain hospitalized without having undergone an operation.Rates of SBR are shown as the percentage of at-risk patients oneach hospital day that underwent bowel resection on that day orsubsequently during the hospitalization. aNumber of at-risk patients

ho underwent SBR on the specified day or at a later point duringhe hospitalization. bAt-risk patients include all those who remainedospitalized without having undergone an operation for adhesivemall bowel obstruction after the specified number of days of non-perative management. Patients who underwent an operation butere missing the data point indicating the time from admission untilperation were excluded.

ospitalization. In contrast, the rates of subsequent SBR

ere 17.3% and 20.5% among those who remained at riskn days 5 (n � 185) or 6 (n � 127), respectively.

Among the subset of patients who underwent operativentervention, the time from admission until operation wasikewise associated with the rate of SBR. The mean timerom admission until SBR was 2.1 � 2.6 days (95% con-idence interval [CI] 1.8 to 2.5) compared with 1.5 � 2.0ays (95% CI 1.3 to 1.6) until LOA (p � 0.001). The ratef SBR was 13.6% (128/940) for patients operated onithin the first day after admission, 19.3% (40/207) foratients receiving an operation on the second day afterdmission, and 22.3% (66/296) for patients who under-ent an operation from 3 to 14 days after admission (p �.003).Additional patient and hospital characteristics in pa-

ients who underwent LOA and SBR are compared in Ta-le 2. Other than time until operation, only hospital typep � 0.006) was associated with operative outcome. Asescribed above, however, the baseline rate of operationas higher at the children’s hospitals. As a fraction of allSBO admissions, the rate of SBR was similar at children’snd nonchildren’s hospitals (119/941 [12.6%] and 148/,031 [14.4%], respectively; p � 0.30). Other patient- andospital-specific factors, including age, sex, race, and insur-nce were not associated with SBR rate.

The association between patient and hospital factorsnd SBR was then assessed by multivariable logistic re-ression (Table 3). Compared with patients who under-ent surgery within the first day after admission, the

djusted odds of SBR was similar on the second day afterdmission (odds ratio [OR] 1.40, 95% CI 0.94 to 2.09)ut increased when surgery was performed on days 3 to4 (OR 1.67, 95% CI 1.19 to 2.34). Compared withhildren’s hospitals, the rate of SBR was similar at non-hildren’s hospitals, but increased (OR 1.85, 95% CI.11 to 3.05) among children whose hospital type wasnknown. Age group, sex, race, and insurance had nossociation with the rate of SBR.

Length of stay was 8.4 � 6.2 days in patients who un-erwent LOA, compared with 11.2 � 7.5 days for patientsequiring SBR (p � 0.001). In-hospital mortality occurredn 8 patients (0.5%) after LOA and 4 (1.4%) after SBRp � 0.11).

DISCUSSIONReview of the nationally representative KID demonstratesthat 85.5% of children and adolescents (aged 2–20 years)admitted with ASBO underwent operative intervention.The use of operative management varied by age, race, andhospital type in univariate analysis, although these findings

should be interpreted with caution considering the high

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rate of missing data, especially for race. For those patientswho did require an operation, delay in surgery was associ-ated with a higher rate of SBR. These data highlight severalkey issues in the management of children and adolescentswith ASBO.

ASBO complicates all types of abdominal operations inchildren and adolescents, but the rates vary by age and typeof initial operation. A population-based analysis of Scottishchildren demonstrated a 4.2% rate of ASBO readmissionin the 5 years after abdominal surgery in children �5 yearsof age, and a 1.1% rate in children �16 years of age.3 Theate was highest for children who underwent surgery on theleum (9.2%), compared with 6.5% after general laparot-my and 2.1% after colonic surgery.13 Similarly, ASBO

occurs in 3.8% of patients after treatment of intra-abdominal tumors, including 8.9% of patients with Wilmstumor.1 ASBO may be more common with some specificbdominal operations, including Ladd procedure.14 Ob-truction is uncommon after appendectomy, however, oc-

Table 2. Characteristics of 1,786 Children and Adolescents

n

Time from admission until operation, d0–1 9402 2073–14 296Unknown 343

Age group, y2–7 4958–14 49215–18 49019–20 309

Sex*Male 1,125Female 637

Race/ethnicityWhite 691Black 211Hispanic 276Other/unknown 608

Primary insurancePrivate 949Medicaid 620Other/unknown 217

Hospital typeChildren’s hospital 859Nonchildren’s hospital 819Unknown 108

*24 patients with missing sex were excluded.

urring in �1% of patients.13,15 f

The proportion of children and adolescents with ASBOwho require operative intervention is debated. Eeson et al5

reported that 84% ultimately required operative interven-tion despite attempted conservative management for amean of 48 hours. Other studies reported that fewer thanone-half of children admitted with ASBO required sur-gery.6,10 Our data support the assertion that most childrennd adolescents (85.5%) admitted with ASBO currentlyndergo operative management. However, we identifiedur cohort using a strict ICD-9-CM search limited to pa-ients identified as having adhesive bowel obstruction. It isossible that some patients with partial obstruction andilder symptoms that resolved conservatively may not

ave been identified. This strict cohort identification washosen to allow uniform comparisons when analyzing risksor bowel resection. Despite this limitation, our data sup-ort the conclusion that operative intervention is widelysed in this clinical scenario.The primary rationale for early operative intervention

rated on for Adhesive Small Bowel Obstructionof adhesions

� 1,493), n(%)

Small bowel resection(n � 293), n (%) p Value

0.00312 (86.4) 128 (13.6)67 (80.7) 40 (19.3)30 (77.7) 66 (22.3)84 (82.8) 59 (17.2)

0.0614 (83.6) 81 (16.4)20 (85.4) 72 (14.6)16 (84.9) 74 (15.1)43 (78.6) 66 (21.4)

0.3246 (84.1) 179 (15.9)24 (82.3) 113 (17.7)

0.7884 (84.5) 107 (15.5)77 (83.9) 34 (16.1)31 (83.7) 45 (16.3)01 (82.4) 107 (17.6)

0.2107 (85.0) 142 (15.0)09 (82.1) 111 (17.9)77 (81.6) 40 (18.4)

0.00640 (86.1) 119 (13.9)71 (81.9) 148 (18.1)82 (75.9) 26 (24.1)

OpeLysis

(n

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95

5125

851

76

or ASBO is to avoid unnecessary bowel resection due to

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ischemia. Currently, however, there are limited data show-ing an association between surgical delay and bowel loss. Infact, some studies have reported no increased risk for com-plications with delayed surgery.5,10,16 Feigin and col-eagues,6 however, reported a 31% rate of SBR among pa-ients requiring operation. All cases of SBR occurred inatients where surgery was delayed �16 hours after admis-ion. They proposed 48 hours as the point when a decisionbout surgery should be made, owing to the increasing riskf strangulation and decreasing chance of nonoperative res-lution. Our data confirm this association between surgicalelay and an increased rate of SBR. The rate of bowelesection was 13.6% for patients operated on within theirst day after admission, 19.3% for those who underwentperation on the second day of hospitalization, and 22.3%ith further delay. When nonoperative management is at-

empted and the patient shows no signs of clinical deterio-ation, our findings support the practice of allowing 1 to 2

Table 3. Factors Associated with Small Bowel Resection ina Multivariable Logistic Regression Model

Odds ratio (95% CI) p Value

Time from admissionuntil operation, d

0–1 1.0 (reference)2 1.40 (0.94–2.09) 0.103–14 1.67 (1.19–2.34) 0.003Unknown 1.11 (0.75–1.64) 0.59

Age group, y2–7 1.0 (reference)8–14 0.89 (0.62–1.26) 0.5015–18 0.86 (0.60–1.24) 0.4219–20 1.23 (0.83–1.84) 0.31

SexMale 1.0 (reference)Female 1.15 (0.88–1.50) 0.30

Race/ethnicityWhite 1.0 (reference)Black 0.98 (0.63–1.52) 0.91Hispanic 0.97 (0.65–1.45) 0.86Other/unknown 1.13 (0.81–1.59) 0.48

Primary insurancePrivate 1.0 (reference)Medicaid 1.30 (0.97–1.75) 0.08Other/unknown 1.12 (0.75–1.68) 0.59

Hospital typeChildren’s hospital 1.0 (reference)Nonchildren’s hospital 1.32 (0.99–1.77) 0.06Unknown 1.85 (1.11–3.05) 0.017

n � 1,762; Hosmer and Lemeshow test: p � 0.48; c-statistic � 0.594.

ays of observation for the obstruction to resolve. Further

elay may increase the likelihood of requiring bowelesection.

Our analysis deliberately excluded children �2 years oldor several reasons. Differentiating cases of ASBO fromther surgical causes of obstruction in this age group isifficult using billing data. Many neonates have long hos-italizations and may have codes from both the primaryurgical etiology, such as gastroschisis, abdominal wall de-ects, or necrotizing enterocolitis, and subsequent adhesivebstructions. Futhermore, billing data may not accuratelyistinguish between true adhesive disease and postopera-ive bowel strictures. Finally, it is widely accepted that thisatient population responds poorly to conservative man-gement.10 The present analysis focused on an older cohort

of children for whom the optimal management is less welldefined.

There are several limitations inherent in the use of ad-ministrative data. This dataset is cross-sectional, so we haveno knowledge of the patients’ earlier surgical history. Wealso lack details about the patients’ prehospital course.Conclusions about the delay from diagnosis until opera-tion therefore begin with the time of admission rather thanthe time of symptom onset. Furthermore, it is possible thatsome patients with ASBO who presented initially withischemic bowel and acute abdominal symptoms may havebeen coded with an alternative primary diagnosis. Thislimitation could explain why other studies have reported ahigher fraction of children with ASBO who require urgentlaparotomy and SBR.5 Missing data was another limita-ion. This is especially important for the analysis of hospitalype, because patients with “unknown” hospital type had aigher rate of SBR. If this data were fully populated, con-lusions about the association between hospital type andurgical outcome may have changed. Finally, this dataset isot equipped to analyze clinical factors, such as tachycar-ia, white blood cell count, physical exam, or imaging find-

ngs, that might predict those patients who are at height-ned risk for bowel resection. Nonetheless, it offers a robustationally representative snapshot of pediatric and adoles-ent admissions for adhesive bowel obstruction and dem-nstrates clearly the association between surgical delay andhe need for bowel resection.

CONCLUSIONSAs many as 85.5% of children and adolescents admittedwith adhesive small bowel obstruction currently un-dergo operative intervention, 16.4% of whom receivesmall bowel resection. The time from admission untiloperation is a strong predictor of bowel resection. Delaybeyond the second day after admission increases the

adjusted odds of SBR 1.67-fold. Our data support the

861Vol. 212, No. 5, May 2011 Lautz et al Pediatric Adhesive Small Bowel Obstruction

recommendation that a decision about operation shouldbe considered within 48 hours after hospital admission.6

Nonoperative management beyond 2 days after admis-sion is appropriate for some children and adolescentswith ASBO. However, the benefit of avoiding an oper-ation must be carefully weighed against the potentiallyincreased risk of bowel resection with further delay on acase by case basis.

Author ContributionsStudy conception and design: Lautz, Raval, Reynolds,

BarsnessAcquisition of data: Lautz, RavalAnalysis and interpretation of data: Lautz, Raval, Reyn-

olds, BarsnessDrafting of manuscript: Lautz, BarsnessCritical revision: Reynolds, Barsness

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