Early enteral nutrition in burns: compliance with guidelines and associated outcomes in a multicenter study.
ABSTRACT Early nutritional support is an essential component of burn care to prevent ileus, stress ulceration, and the effects of hypermetabolism. The American Burn Association practice guidelines state that enteral feedings should be initiated as soon as practical. The authors sought to evaluate compliance with early enteral nutrition (EN) guidelines, associated complications, and hospitalization outcomes in a prospective multicenter observational study. They conducted a retrospective review of mechanically ventilated burn patients enrolled in the prospective observational multicenter study "Inflammation and the Host Response to Injury." Timing of initiation of tube feedings was recorded, with early EN defined as being started within 24 hours of admission. Univariate and multivariate analyses were performed to distinguish barriers to initiation of EN and the impact of early feeding on development of multiple organ dysfunction syndrome, infectious complications, days on mechanical ventilation, intensive care unit (ICU) length of stay, and survival. A total of 153 patients met study inclusion criteria. The cohort comprised 73% men, with a mean age of 41 ± 15 years and a mean %TBSA burn of 46 ± 18%. One hundred twenty-three patients (80%) began EN in the first 24 hours and 145 (95%) by 48 hours. Age, sex, inhalation injury, and full-thickness burn size were similar between those fed by 24 hours vs after 24 hours, except for higher mean Acute Physiology and Chronic Health Evaluation II scores (26 vs 23, P = .03) and smaller total burn size (44 vs 54% TBSA burn, P = .01) in those fed early. There was no significant difference in rates of hyperglycemia, abdominal compartment syndrome, or gastrointestinal bleeding between groups. Patients fed early had shorter ICU length of stay (adjusted hazard ratio 0.57, P = 0.03, 95% confidence interval 0.35-0.94) and reduced wound infection risk (adjusted odds ratio 0.28, P = 0.01, 95% confidence interval 0.10-0.76). The investigators have found early EN to be safe, with no increase in complications and a lower rate of wound infections and shorter ICU length of stay. Across institutions, there has been high compliance with early EN as part of the standard operating procedure in this prospective multicenter observational trial. The investigators advocate that initiation of EN by 24 hours be used as a formal recommendation in nutrition guidelines for severe burns, and that nutrition guidelines be actively disseminated to individual burn centers to permit a change in practice.
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ABSTRACT: Significance: Nutrition has been recognized as a critical component of acute burn care and ultimate wound healing. Debate remains over the appropriate timing of enteral nutrition and the benefit of supplemental trace elements, antioxidants, and immunonutrition for critically ill burn patients. Pharmacotherapy to blunt the metabolic response to burn injury plays a critical role in effective nutritional support. Recent Advances: Further evidence is demonstrating long-term benefits from pharmacologic immunomodulation given the prolonged metabolic response to injury that may last for over a year following the initial insult. Critical Issues: The majority of evidence regarding early enteral feeding comes from mixed populations and smaller studies. However, on balance, available evidence favors early feeding. Data regarding immunonutrition does not support the routine use of these products. Limited data regarding use of antioxidants and trace elements support their use. Future Directions: Further evaluation of anti-inflammatory mediators of the immune response, such as statins, will likely play a role in the future. Further data are needed on the dosing and route of micronutrients as well as the utility of immunonutrition. Finally, little is known about nutrition in the obese burn patient making this an important area for investigation.Advances in wound care. 01/2014; 3(1):64-70.
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ABSTRACT: Severe weight loss resulting from inadequate nutritional intake along with the hypermetabolism after thermal injury can result in impaired immune function and delayed wound healing. This observational study was conducted on adults admitted between October 2007 and April 2012 with at least 20% total body surface area burn requiring excision who previously tolerated gastric enteral nutrition at calorie goal and who returned from surgery hemodynamically stable (no new pressor requirement) and compared the effect of goal rate re-initiation versus slow re-initiation after the first excision and grafting. Demographic, intake, and tolerance data were collected during the 36h following surgery and were analyzed with descriptive and comparative statistics. Data were collected on 14 subjects who met the inclusion criteria. Subjects in the goal rate re-initiation group (n=7) met a significantly greater percentage of caloric goals (99±12% versus 58±21%, p=0.003) during the 36h following surgery than subjects in the slow re-initiation group (n=7). There were no incidences of emesis, aspiration, or ischemic bowel in either group. The goal rate re-initiation group had a 29% incidence of either stool output >1L (n=1) or gastric residual volumes >500mL (n=1), whereas these were not present in the slow re-initiation group (p=0.462). In conclusion, in this small pilot study, we found that enteral nutrition could be re-initiated after the first excision and grafting in those patients who previously tolerated gastric enteral nutrition meeting caloric goals who return from surgery hemodynamically stable without a significant difference in intolerance and with a significantly higher percentage of calorie goals achieved, but larger studies are required.Burns: journal of the International Society for Burn Injuries 07/2014; · 1.95 Impact Factor
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ABSTRACT: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are complications that may occur in severely burned patients. Evidenced based medicine for these patients is in its early development. The aim of this study was to provide an overview of literature regarding IAH and ACS in severely burned patients. A systematic search was performed in Cochrane Central Register of Controlled Trials, PubMed, Embase, Web of Science and CINAHL on October 1, 2012. These databases were searched on 'burn', 'intra-abdominal hypertension', 'abdominal compartment syndrome', synonyms and abbreviations. Studies reporting original data on mortality, abdominal decompression or abdominal pressure related complications were included. Fifty publications met the criteria, reporting 1616 patients. The prevalence of ACS and IAH in severely burned patients is 4.1-16.6% and 64.7-74.5%, respectively. The mean mortality rate for ACS in burn patients is 74.8%. The use of plasma and hypertonic lactated resuscitation may prevent IAH or ACS. Despite colloids decrease resuscitation volume needs, no benefit in preventing IAH was proven. Escharotomy, peritoneal catheter drainage, and decompression laparotomy are effective intra-abdominal pressure (IAP) diminishing treatments in burn patients. Markers for IAP-related organ damage might be superior to IAP measurement itself. ACS and IAH are frequently seen devastating complications in already severely injured burn patients. Prevention is challenging but can be achieved by improving fluid resuscitation strategies. Surgical decompression measures are effective and often unavoidable. Timing is essential since decompression should prevent progression to ACS rather than limit its effects. Prognosis of ACS remains poor, but options for care improvement are available in literature.Burns: journal of the International Society for Burn Injuries 09/2013; · 1.95 Impact Factor
Early Enteral Nutrition in Burns: Compliance With
Guidelines and Associated Outcomes in a
Michael J. Mosier, MD,* Tam N. Pham, MD,† Matthew B. Klein, MD,†
Nicole S. Gibran, MD,† Brett D. Arnoldo, MD,‡ Richard L. Gamelli, MD,*
Ronald G. Tompkins, MD, ScD,§ David N. Herndon, MD?
Early nutritional support is an essential component of burn care to prevent ileus, stress ulcer-
ation, and the effects of hypermetabolism. The American Burn Association practice guidelines
state that enteral feedings should be initiated as soon as practical. The authors sought to evalu-
ate compliance with early enteral nutrition (EN) guidelines, associated complications, and
hospitalization outcomes in a prospective multicenter observational study. They conducted a
retrospective review of mechanically ventilated burn patients enrolled in the prospective obser-
vational multicenter study “Inflammation and the Host Response to Injury.” Timing of initia-
tion of tube feedings was recorded, with early EN defined as being started within 24 hours of
admission. Univariate and multivariate analyses were performed to distinguish barriers to initia-
tion of EN and the impact of early feeding on development of multiple organ dysfunction syn-
drome, infectious complications, days on mechanical ventilation, intensive care unit (ICU)
length of stay, and survival. A total of 153 patients met study inclusion criteria. The cohort
comprised 73% men, with a mean age of 41 ? 15 years and a mean %TBSA burn of 46 ? 18%.
One hundred twenty-three patients (80%) began EN in the first 24 hours and 145 (95%) by 48
hours. Age, sex, inhalation injury, and full-thickness burn size were similar between those fed
by 24 hours vs after 24 hours, except for higher mean Acute Physiology and Chronic Health
Evaluation II scores (26 vs 23, P ? .03) and smaller total burn size (44 vs 54% TBSA burn,
P ? .01) in those fed early. There was no significant difference in rates of hyperglycemia, ab-
dominal compartment syndrome, or gastrointestinal bleeding between groups. Patients fed
early had shorter ICU length of stay (adjusted hazard ratio 0.57, P ? 0.03, 95% confidence in-
terval 0.35–0.94) and reduced wound infection risk (adjusted odds ratio 0.28, P ? 0.01, 95%
confidence interval 0.10–0.76). The investigators have found early EN to be safe, with no in-
crease in complications and a lower rate of wound infections and shorter ICU length of stay.
Across institutions, there has been high compliance with early EN as part of the standard operating
procedure in this prospective multicenter observational trial. The investigators advocate that initi-
ation of EN by 24 hours be used as a formal recommendation in nutrition guidelines
for severe burns, and that nutrition guidelines be actively disseminated to individual
burn centers to permit a change in practice. (J Burn Care Res 2011;32:104–109)
Severe burn injury results in a prolonged hypermeta-
bolic and catabolic state that persists as long as 1 year
after injury.1Early nutritional support has become a
critical component of early management of injured
patients to prevent ileus, stress ulceration, and the
effects of hypermetabolism. International nutrition
support guidelines advocate that enteral feedings
should occur early in critically ill patients who have a
From the *Loyola University Medical Center, Maywood, Illinois;
†University of Washington Burn Center, Harborview Medical
Center, Seattle; ‡University of Texas Southwestern Parkland
Memorial Hospital, Dallas; §Massachusetts General Hospital,
Boston; and ?University of Texas Medical Branch, Galveston.
Supported by the National Institute of General Medical Sciences.
This article was prepared using a dataset obtained from the Glue
Grant program and does not necessarily reflect the opinions or
views of the Inflammation and the Host Response to Injury
Investigators or the NIGMS.
Address correspondence to Michael J. Mosier, MD, Loyola
University Medical Center, Department of Surgery, EMS
Building 110, 2160 South First Avenue, Maywood, IL 60153.
Copyright © 2011 by the American Burn Association.
functioning gastrointestinal tract, but what is consid-
ered early varies significantly.2–5The Canadian Clin-
ical Practice Guidelines recommend starting enteral
nutrition (EN) within 24 to 48 hours after admission
to the intensive care unit (ICU) in critically ill pa-
tients.3The Eastern Association for the Surgery of
Trauma recommends that intragastric feedings be
started as soon as possible in burn patients after ad-
results in a high rate of gastroparesis and the need for
intravenous nutrition.4Similarly, the American Burn
Association (ABA) advocates early EN as soon as
The practice of early enteral feeding was one of the
standard practice guidelines adopted by the Inflamma-
tion and Host Response to Injury (Glue Grant). The
Glue Grant standard operating procedures state that
EN should be started as soon as possible after admis-
sion.6However, both ABA and Glue Grant guidelines
ations in practice to be a potential barrier to uniformity
within a prospective multicenter trial.
Increasing emphasis is now placed on practice
guidelines, protocols, and bundles in all areas of crit-
ical care, including burns.7–9The impact of guide-
studies have evaluated compliance. Recognized bar-
riers to compliance include patient and injury factors,
logistical issues, and individual institutional practices
or provider preferences. We sought to evaluate com-
pliance with early EN, possible barriers to implemen-
tation, associated complications, and hospitalization
outcomes in a prospective multicenter observational
The Inflammation and Host Response to Injury is a
collaborative program supported by the National In-
to evaluate current practices in EN and examine the
logistical, patient, injury, resuscitation, or provider
characteristics that may contribute to a delay in EN
and 2) to examine the relationship between early EN
and hospital outcomes. The principal exposure of
interest was early EN, defined as initiation of tube
feeding within the first 24 hours postburn injury.
Outcomes of interest were complications associated
with early feeding, multiple organ dysfunction syn-
drome, infectious complications, ventilator days,
ICU length of stay (LOS), and in-hospital mortality.
Patients and Data Collection
Eligible subjects included all mechanically ventilated
adults with complete outcome data enrolled in the
burn arm of the “Inflammation and Host Response
to Injury” program from March 2004 to September
2009. We chose mechanically ventilated adults to
evaluate the most severely ill cohort and to eliminate
variations in supplementing oral nutrition with tube
feeding.10Criteria for adult patient enrollment into
each of the five participating sites study were age 18
years or older, burn size ?20% TBSA, no other con-
comitant trauma, and admission within 96 hours of
injury. Patients who were not resuscitated and placed
on comfort care were not eligible for enrollment. Pa-
tients and their families were interviewed about their
medical history and when available, medical records
before injury were also reviewed to learn about med-
With respect to clinical management, investigators
from all participating sites agreed to adhere to stan-
dard management protocols and defined all clinical
variables to be prospectively recorded, as previously
described.6Clinical data were collected by trained
nurse abstractors and entered into a web-based data
collection platform specifically adapted for this pro-
gram. Data integrity was evaluated centrally and by
external review as previously described.10For this
study, we abstracted data on all enrolled mechanically
ventilated adult patients with complete hospitaliza-
tion records as of September 1, 2009. Approval for
the study was granted by the Glue Grant administra-
tive core and by the University of Washington Insti-
tutional Review Board.
We compared baseline patient and injury characteris-
tics between patients who received and who did not
receive early EN, including age, sex, ethnicity,
%TBSA burn, injury etiology, presence of inhalation
injury, Acute Physiology and Chronic Health Evalu-
ation (APACHE) II score, Denver multiorgan failure
score10at 24 hours and maximal Denver score, resus-
citation volume, urine output, and development of
abdominal compartment syndrome. Total fluid vol-
ume (including colloid and crystalloid) administered
in the first 24 hours after injury was examined as a
ratio over the volume predicted by the Parkland for-
mula (4 ml/kg/%TBSA). Development of complica-
tions, days requiring mechanical ventilation, ICU
LOS, and mortality were recorded for each patient.
Categorical variables, reported as proportions,
were compared with ?2tests. Continuous variables
are reported as mean ? SD. Means were compared
Journal of Burn Care & Research
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Mosier et al
using Student’s t-test if a normal distribution was
detected. Nonparametric variables were compared
with Wilcoxon rank-sum test where appropriate. Lo-
impact of early EN on complications and hospitaliza-
To adjust for confounding variables and assess pos-
sible effect modification, multiple logistic regression
analyses were performed, including all variables that
demonstrated significant association with the out-
come of interest in the bivariate analyses (at the P
?.20 level). Time-to-event analyses were performed
by Cox proportional hazard ratio model. The model
included known factors that contribute to burn out-
comes (age, %TBSA, and presence of inhalation in-
jury), as well as participating center, to control for
potential variability among participating sites. All sta-
tistical analyses were performed with the use of
STATA 10 (College Station, TX), a statistical soft-
ware package. Actual P values are reported.
At the time of our analysis, there were a total of 229
enrolled adult subjects with complete and validated
data. We restricted the study population to 153 me-
comprised 73% men, with a mean age of 41 ? 15 years
and a mean %TBSA burn of 46 ? 18%. Of these 153
patients, 123 patients (80%) received EN by 24 hours,
and 145 patients (95%) received EN by 48 hours. Four
participating centers initiated EN via gastric tubes,
whereas one site used postpyloric feeding tubes.
Potential Barriers to Early Feeding
We attempted to systemically evaluate logistical, pa-
tient, and injury factors that may have impacted the
timing of EN initiation (Table 1). Differences in age,
sex, inhalation injury, and full-thickness burn size
were not statistically significant between groups, with
the exception that patients fed in the first 24 hours
had a higher mean APACHE II score (26 vs 23,
P ? .03), despite smaller overall burn size (44 vs
54% TBSA burn, P ? .01). From a logistical stand-
point, there was no difference in mean time from
injury to admission between groups (3.4 vs 4.0
hours, P ? .28), and the time of day that patients
were injured and admitted were similar between
groups (P ? 0.80 and 0.96, respectively). No pa-
tients had associated abdominal trauma that would
influence the decision to feed.
To assess the resuscitation factors that might have
influenced the timing of EN, we examined fluid
requirements, development of abdominal compart-
ment syndrome, hyperglycemia, insulin require-
ments, vasopressors, and early complications and
found no statistical differences between the two
groups (Table 2). Specifically, use of vasopressors was
not associated with initiation of EN, as 10% of pa-
tients in each group received vasopressors in the first
Next, we compared injury outcomes between those
who received EN and those who did not. There was
no increased incidence of gastrointestinal bleeding,
abdominal compartment syndrome, need for laparot-
omy, or ventilator-associated pneumonia (Table 3).
We also evaluated the influence of early EN on time
to ventilator-associated pneumonia development and
found that early EN was not a significant predictor
(adjusted hazard ratio [HR] ? 1.23, P ? .41, 95%
confidence interval [CI] 0.74–2.04). In addition,
length of mechanical ventilation, incidence of blood-
stream and total infectious complications, multiple
organ dysfunction syndrome, and survival were sim-
ilar between the two groups. Patients fed early did
have a shorter ICU LOS (40.7 vs 52.5 days, P ? .03)
and decreased wound infection rates (54.5 vs 80%,
P ? .01).
After adjustment for age, %TBSA burn, inhalation
injury, and participating burn center, patients fed in
the first 24 hours still had a shorter ICU LOS (ad-
justed HR ? 0.57, P ? .03, 95% CI 0.35–0.94) and
CI 0.10–0.76). Participating sites did not signifi-
cantly influence the outcomes of wound infections,
development of pneumonia, or prolonged mechani-
cal ventilation. Participating sites, however, had a
modifying effect on ICU LOS (adjusted HR ? 0.85,
P ? .04, 95% CI 0.74–0.99; Table 4). As shown in
Table 1. Patient demographics for early enteral nutrition
in intubated adults
(SD) or %
(n ? 153)
(n ? 123)
(n ? 30)
Percent TBSA burn
56 59 43.13
.03 25 (7)26 (7)23 (7)
EN, enteral nutrition; APACHE, Acute Physiology and Chronic Health
Journal of Burn Care & Research
Mosier et al
Figure 1, mean ICU LOS was shorter for patients fed
within 24 hours at four sites and nearly equivalent at
the fifth burn center.
Accordingly, the ABA guidelines state that “enteral
feedings should be initiated as soon as practical.”5In
this multicenter prospective study, the standard op-
erating procedures similarly emphasize the impor-
tance of early nutrition, recommending that “enteral
nutrition should be started as soon as possible.”6
When examining adherence to these guidelines, we
found a high compliance among participating centers
with 80% (123) to 95% (145) of patients being fed in
the first 24 to 48 hours.
We examined the potential barriers to initiating
feeds within the first day of admission, looking for
logistical, patient, injury, or resuscitation factors that
may have impacted initiation of feeding. However,
within 24 hours and those after 24 hours. Thus, they
likely were not the principal barriers for early EN initia-
accounted for the variation in practice.
demonstrated numerous advantages, such as in-
creased caloric intake, insulin secretion and protein
retention,11improved bowel mucosal integrity,12
and decreased incidence of stress gastritis.13A recent
review of patients treated over 30 years indicates that
modern resuscitation combined with early EN has
nearly eliminated the incidence of significant stress
ulceration.13However, it has been difficult to show
impact on nutritional, metabolic, or biochemical
rates, and mortality.14
There have been many concerns regarding early
potential for intestinal necrosis in patients undergo-
ing resuscitation11,14or fear for aspiration and asso-
ciated pneumonia, although a recent study showed
no increased risk of aspiration or pneumonia in pa-
tients who were fed early.15We believe that many
Table 2. Resuscitation factors
Variable Mean (SD) or % All (n ? 153)Early EN (n ? 123) EN After 24 hr (n ? 30)
Fluid resuscitation (observed/expected)
Abdominal compartment syndrome
24-hr high glucose (mg/dl)
24-hr insulin requirement (U)
Received pressors in first 24 hr
ALI at 24 hr
AKI at 24 hr
MODS at 24 hr
ALI, acute lung injury; AKI, acute kidney injury; MODS, multiple organ dysfunction syndrome.
Table 3. Hospital Outcomes with Early
(n ? 153)
(n ? 123)
(n ? 30)
Vent days ?21 (%)
Blood infection (%)
Wound infection (%)
GI bleed (%)
ICU LOS (d)
VAP, ventilator-associated pneumonia; ARDS, acute respiratory distress
syndrome; MODS, multiple organ dysfunction syndrome; ICU LOS, inten-
sive care unit length of stay.
Table 4. Analysis of factors associated with higher
Early EN initiation
Age (per yr)
TBSA (per %)
EN, enteral nutrition; ICU LOS, intensive care unit length of stay; CI,
Journal of Burn Care & Research
Volume 32, Number 1
Mosier et al
aspirations, especially microaspirations, occur fre-
quently and may not become apparent until infection
is present. Thus, we defined ventilator-associated
pneumonia as the clinically important endpoint that
encompasses complications related to aspiration
events. Also, we found no harmful effects of early
feeding of severely burned patients, as there was no
increased incidence of gastrointestinal bleeding, lap-
arotomy for abdominal compartment syndrome, or
ischemic bowel, even while 10% of patients received
vasopressors during resuscitation.
We also examined the potential impact of earlier
enteral feeding on injury outcome. Two previous
small trials of early EN in burn patients have shown
no difference between early and late feeding for LOS,
Conversely, Hart et al17have shown a significant de-
burn wound excision, independent of the metabolic
rate. Although our study may suggest some benefit to
early EN, prospective evaluations with well-defined EN
protocols are needed to answer whether early EN has
positive effects on wound infection rates, duration of
cifically worded practice guidelines with protocolized
initiation of EN may help unify practice patterns and
facilitate future attempts to answer these questions.
It is certainly valid to ask the question, “Is there
hours?” Some practitioners are advocating waiting
Perhaps to find a difference between groups, very
early feeding would need to be performed. Animal
studies have shown safety in feeding 2 hours after
injury, with ability to decrease the hypermetabolic
and catabolic response to injury as well as decreased
bacterial translocation,18–22but human studies have
failed to replicate this finding.
This study has several limitations. Our study is ret-
rospective in nature and across multiple institutions.
Although we have systematically assessed patient, in-
jury, and logistical factors that may affect the timing
of EN initiation, potential systematic variability be-
tween centers not associated with the start of tube
come differences. Standard operating protocols for
the Glue Grant project were intended to decrease
variability. However, center variability still signifi-
observed center effect on ICU LOS. Also, we did not
have data on the amount of calories provided to each
subject per day, whether individual patients achieved
caloric goals (and how soon), nor did we capture data
on metabolic and nutritional parameters at regular
intervals. As such, we were unable to assess whether
those subjects who were started on early EN achieved
nutritional goals earlier or whether early EN influ-
enced postburn hypermetabolism. In addition, in the
immediate resuscitation period, patients are often
transferred from nonburn facilities and require initial
stabilization, including bedside procedures and
wound care. Thus, it can be logistically difficult to
initiate feeding as quickly as can be performed in an
animal study. The dataset did not specify the exact
hour of initiation of EN and thus did not permit
subgroup analysis within those fed by 24 hours. As
considered early compared with many studies that
have looked at late feeding), there may be little dif-
ference between those fed late on the day of admis-
sion and early on the second day.
Experience with nutrition guidelines in critical care
indicates that ICUs with a feeding protocol achieve
more adequate EN and that an active dissemination
of clinical practice guidelines is much more effective
than passive.23,24These elements highlight that lack
of a unit-specific protocol or awareness of a practice
guideline constitutes barriers to its implementation.
Therefore, we advocate that initiation of EN by 24
hours be used as a formal recommendation in nutri-
tion guidelines for severe burns and that nutrition
guidelines be actively disseminated to individual burn
centers to permit a change in practice.
We have found high compliance with early EN in this
prospective, multicenter observational trial, such that
80% (123) to 95% (145) of patients were fed in the
first 24 to 48 hours, respectively, although some vari-
ation exists among participating institutions. There
was no demonstrable harm from early EN and per-
haps measurable benefits, with noted decreases in
ICU LOS and incidence of wound infections. We
Figure 1. Mean intensive care unit length of stay (days) by
Journal of Burn Care & Research
Mosier et al
advocate that initiation of EN by 24 hours be used as
a formal recommendation in nutrition guidelines for
severe burns and that nutrition guidelines be actively
disseminated to individual burn centers to permit a
change in practice.
The investigators acknowledge the contribution of the
Collaborative Project Award 2-U54-GM062119 from the
National Institute of General Medical Sciences, the Na-
tional Center for Research Resources (NCCR) Grant
1KL2RR025015-01, and the David and Nancy Auth-
Washington Research Foundation Endowment.
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