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ABSTRACT: OBJECTIVES: To investigate whether the development of hypokalemia in patients with diabetic ketoacidosis (DKA) treated in the pediatric critical care unit (PCCU) could be caused by increased potassium (K(+)) excretion and its association with insulin treatment. STUDY DESIGN: In this prospective observational study of patients with DKA admitted to the PCCU, blood and timed urine samples were collected for measurement of sodium (Na(+)), K(+), and creatinine concentrations and for calculations of Na(+) and K(+) balances. K(+) excretion rate was expressed as urine K(+)-to-creatinine ratio and fractional excretion of K(+). RESULTS: Of 31 patients, 25 (81%) developed hypokalemia (plasma K(+) concentration <3.5 mmol/L) in the PCCU at a median time of 24 hours after therapy began. At nadir plasma K(+) concentration, urine K(+)-to-creatinine ratio and fractional excretion of K(+) were greater in patients who developed hypokalemia compared with those without hypokalemia (19.8 vs 6.7, P = .04; and 31.3% vs 9.4%, P = .004, respectively). Patients in the hypokalemia group received a continuous infusion of intravenous insulin for a longer time (36.5 vs 20 hours, P = .015) and greater amount of Na(+) (19.4 vs 12.8 mmol/kg, P = .02). At peak kaliuresis, insulin dose was higher in the hypokalemia group (median 0.07, range 0-0.24 vs median 0.025, range 0-0.05 IU/kg; P = .01), and there was a significant correlation between K(+) and Na(+) excretion (r = 0.67, P < .0001). CONCLUSIONS: Hypokalemia was a delayed complication of DKA treatment in the PCCU, associated with high K(+) and Na(+) excretion rates and a prolonged infusion of high doses of insulin.
The Journal of pediatrics 02/2013; · 4.02 Impact Factor
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ABSTRACT: This is the first large multicenter study to examine the effectiveness of a pediatric rapid response system (PRRS). The primary objective was to determine the effect of a PRRS using a physician-led team on the rate of actual cardiopulmonary arrests, defined as an event requiring chest compressions, epinephrine, or positive pressure ventilation. The secondary objectives were to determine the effect of PRRSs on the rate of PICU readmission within 48 hours of discharge and PICU mortality after readmission and urgent PICU admission.
A PRRS was developed, implemented, and evaluated in a standardized manner across 4 pediatric academic centers in Ontario, Canada. The team responded to activations for inpatients and followed patients discharged from the PICU for 48 hours. A 2-year, prospective, observational study was conducted after implementation, and outcomes were compared with data collected 2 years before implementation.
After PRRS implementation, there were 55 963 hospital admissions and a team activation rate of 44 per 1000 hospital admissions. There were 7302 patients followed after PICU discharge. Implementation of the PRRS was not associated with a reduction in the rate of actual cardiopulmonary arrests (1.9 vs 1.8 per 1000 hospital admissions; P=.68) or PICU mortality after urgent admission (1.3 vs 1.1 per 1000 hospital admissions; P=.25). There was a reduction in the PICU mortality rate after readmission (0.3 vs 0.1 death per 1000 hospital admissions; P=.05).
The standardized implementation of a multicenter PRRS was associated with a decrease in the rate of PICU mortality after readmission but not actual cardiopulmonary arrests.
PEDIATRICS 06/2011; 128(1):72-8. · 4.47 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate observed/expected (O/E) lung-to-head ratio (LHR) by ultrasound (US) and total fetal lung volume (TFLV) by magnetic resonance imaging as neonatal outcome predictors in isolated fetal congenital diaphragmatic hernia (CDH).
We conducted a retrospective study of 72 fetuses with isolated CDH, in whom O/E LHR and TFLV were evaluated as survival predictors.
O/E LHR on US and O/E TFLV by magnetic resonance imaging were significantly lower in newborn infants with isolated CDH who died compared with survivors (30.3 ± 8.3 vs 44.2 ± 14.2; P < .0001 for O/E LHR; 21.9 ± 6.3 vs 41.5 ± 17.6; P = .001 for O/E TFLV). Area under receiver-operator characteristics curve for survival for O/E LHR was 0.80 (95% confidence interval, 0.70-0.90). On multivariate analysis, O/E LHR predicted survival, whereas hernia side and first neonatal pH did not. For each unit increase in O/E LHR, mortality odds decreased by 11% (95% confidence interval, 4-17%).
In fetuses with isolated CDH, O/E LHR (US) independently predicts survival and may predict severity, allowing management to be optimized.
American journal of obstetrics and gynecology 02/2011; 205(1):43.e1-8. · 3.28 Impact Factor
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ABSTRACT: To evaluate the accuracy of central venous oxygen saturation recordings from a new in-line pediatric oximetry catheter.
Prospective, observational study.
Eighteen pediatric patients who needed central venous access for monitoring and/or treatment between January 2006 and June 2006 in the pediatric intensive care unit of the Hospital for Sick Children in Toronto, Canada.
Measurements were done at the baseline and then every 4-8 hrs. The monitor was calibrated in vivo at the baseline and then daily. In vitro calibration of the monitor was also performed in the last five patients. The hemoglobin value was updated when there was a significant change. The maximum duration of sampling was 72 hrs (if indicated). There were 131 measurements in 17 patients; each subject had a different number of paired measurements (median 5). Three patients were excluded due to violation of the protocol, and 113 measurements were left in analysis. The mean difference of catheter value from the laboratory value was -1.01 (median 0). The interquartile range was 5. The difference of both methods was evenly distributed as per a Bland-Altman plot, with one patient's data lying outside of the comparable limits of ± 1.96 sd from the mean differences. The relationship of the difference between the catheter data and the lab data to the independent variables (age, weight, gender, catheter tip, diagnosis, and signal quality index) was estimated by using the multiple regression analysis (version 9.1, SAS Institute, Cary, NC). All variables were eliminated. The Pearson correlation coefficient between lab-mixed venous oxygen saturation and oximetry catheter readings for measurements was 0.88.
In this limited number of patients, use of the PediaSat venous oximetry catheter was safe and had good agreement with co-oximetry-measured values.
Pediatric Critical Care Medicine 10/2010; 12(4):437-41. · 3.13 Impact Factor
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ABSTRACT: To establish the incidence and factors associated with hospital-acquired hyponatremia in pediatric surgical patients who received hypotonic saline (sodium 40 mmol/L plus potassium 20 mmol/L) at the rate suggested by the Holliday and Segar's formula for calculations of maintenance fluids.
Prospective, observational, cohort study.
Pediatric intensive care unit.
: Eighty-one postoperative patients.
None.
Incidence and factors associated with hyponatremia (sodium < or = 135 mmol/L). Univariate analysis was conducted post surgery at 12 hrs and at 24 hrs. Mean values were compared with independent t test samples. Receiver operating characteristics curve analysis was performed in variables with a p <.05, and relative risks were calculated. Eighty-one patients were included in the study. The incidence of hyponatremia at 12 hrs was 17 (21%) of 81 (95% confidence interval, 3.7-38.3); at 24 hrs, it was was 15 (31%) of 48 (95% confidence interval, 11.4-50.6). Univariate analysis at 12 hrs showed that hyponatremic patients had a higher sodium loss (0.62 mmol/kg/hr vs. 0.34 mmol/kg/hr, p = .0001), a more negative sodium balance (0.39 mmol/kg/hr vs. 0.13 mmol/kg/hr, p < .0001), and a higher diuresis (3.08 mL/kg/hr vs. 2.2 mL/kg/hr, p = .0026); relative risks were 11.55 (95% confidence interval, 2.99-44.63; p = .0004) for a sodium loss >0.5 mmol/kg/hr; 10 (95% confidence interval, 2.55-39.15; p = .0009) for a negative sodium balance >0.3 mmol/kg/hr; and 4.25 (95% confidence interval, 1.99-9.08; p = .0002) for a diuresis >3.4 mL/kg/hr. At 24 hrs, hyponatremic patients were in more positive fluid balance (0.65 mL/kg/hr vs. 0.10 mL/kg/hr, p = .0396); relative risk was 3.25 (95% confidence interval, 1.2-8.77; p = .0201), for a positive fluid balance >0.2 mL/kg/hr.
The incidence of hyponatremia in this population was high and progressive over time. Negative sodium balance in the first 12 postoperative hours and then a positive fluid balance could be associated with the development of postoperative hyponatremia.
Pediatric Critical Care Medicine 07/2010; 11(4):479-83. · 3.13 Impact Factor
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ABSTRACT: The aim of this study is to determine if there has been a true, absolute, or apparent relative increase in congenital diaphragmatic hernia (CDH) survival for the last 2 decades.
All neonatal Bochdalek CDH patients admitted to an Ontario pediatric surgical hospital during the period when significant improvements in CDH survival was reported (from January 1, 1992, to December 31, 1999) were analyzed. Patient characteristics were assessed for CDH population homogeneity and differences between institutional and vital statistics-based population survival outcomes. SAS 9.1 (SAS Institute, Cary, NC) was used for analysis.
Of 198 cohorts, demographic parameters including birth weight, gestational age, Apgar scores, sex, and associated congenital anomalies did not change significantly. Preoperative survival was 149 (75.2%) of 198, whereas postoperative survival was 133 (89.3%) of 149, and overall institutional survival was 133 (67.2%) of 198. Comparison of institution and population-based mortality (n = 65 vs 96) during the period yielded 32% of CDH deaths unaccounted for by institutions. Yearly analysis of hidden mortality consistently showed a significantly lower mortality in institution-based reporting than population.
A hidden mortality exists for institutionally reported CDH survival rates. Careful interpretation of research findings and more comprehensive population-based tools are needed for reliable counseling and evaluation of current and future treatments.
Journal of Pediatric Surgery 06/2009; 44(5):877-82. · 1.45 Impact Factor
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ABSTRACT: The purpose of the study was to describe the mechanisms of injury and causes of death in children dying in a modern, integrated trauma system.
Records of all children (<16 years of age) who died in Ontario from 2001 through 2003 after blunt or penetrating trauma were obtained from the Chief Coroner. Demographics and the nature and causes of injury and the causes of death were recorded. Estimates of the mortality rate were determined using census data.
There were 234 injury deaths (222 blunt, 12 penetrating) over the 3 years. Thirty (13%) resulted from intentional injury. The median age was 10 (range, 0-15.9) years; 62% were male. Sixty-eight percent resulted from incidents involving motor vehicles (passenger, pedestrian, or cyclist). Most (74%) died at the scene; only 5% survived for more than 24 hours. Devastating craniocervical injury (Abbreviated Injury Scale 5 or 6) was present in 84% and was the only life-threatening injury in 40%. The annual mortality rate averaged 3.2 per 100,000 children.
In a modern, integrated trauma system, most pediatric injury deaths occur at the scene from severe head injuries. In this population, strategies to reduce the death rate from pediatric trauma must focus on primary and secondary injury prevention.
Journal of Pediatric Surgery 05/2009; 44(5):981-6. · 1.45 Impact Factor
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ABSTRACT: Previously, we demonstrated that 21% of pediatric (<16 years) trauma deaths in the Province of Ontario during the period 1985 to 1987 were potentially preventable. Since then many trauma system changes have occurred including field triage, designation of trauma centers, and improved injury prevention. This study aims to examine the current preventable trauma death rate in our system using identical methodology to our previous study.
The records of all children (<16 years) who died in Ontario from 2001 to 2003 after blunt or penetrating trauma were obtained from the Chief Coroner and compared with those in our previous report. In both series, we excluded cases where care was not sought and all deaths due to asphyxia. Deaths were considered unpreventable if the Injury Severity Score, based on Abbreviated Injury Scale 1985, was >59; or if there was a head injury that received an Abbreviated Injury Scale score of 5 with the exception of isolated extra-axial hematomas.
Eleven preventable deaths were identified. The preventable death rate was 7%, a significant decline from the 21% previously identified (p < 0.001; relative risk reduction for preventable death, 68% [95% confidence interval, 42-83%]; number needed to treat, 7).
There has been a threefold decline in the preventable death rate, which we believe is related to improvements in the trauma system. We estimated that, for every seven deaths from fatal injuries, system changes between the two study periods eliminated one preventable death.
The Journal of trauma 05/2009; 66(4):1189-94; discussion 1194-5. · 2.48 Impact Factor
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ABSTRACT: The occurrence of acute hyponatremia associated with cerebral edema in hospitalized children has been increasingly recognized, with over 50 cases of neurological morbidity and mortality reported in the past decade. This condition most commonly occurs in previously healthy children where maintenance intravenous (IV) fluids have been prescribed in the form of hypotonic saline (e.g., 0.2 or 0.3 NaCl). In response to similar problems at The Hospital for Sick Children (six identified through hospital morbidity and mortality reviews and safety reports prior to fall 2007), an interdisciplinary clinician group from our institution developed a clinical practice guideline (CPG) to guide fluid and electrolyte administration for pediatric patients. This article reviews the evaluation of one patient safety improvement to change the prescribing practice for IV fluids in an acute care pediatric hospital, including the removal of the ability to prescribe hypotonic IV solutions with a sodium concentration of < 75 mmol/L. The evaluation of key components of the CPG included measuring practice and process changes pre- and post-implementation. The evaluation showed that the use of restricted IV fluids was significantly reduced across the organization. Success factors of this safety initiative included the CPG development, forcing functions, reminders, team engagement and support from the hospital leadership. A key learning was that a project leader with considerable dedicated time is required during the implementation to develop change concepts, organize and liaise with stakeholders and measure changes in practice. This project highlights the importance of active implementation for policy and guideline documents.
Healthcare quarterly (Toronto, Ont.) 01/2009; 12 Spec No Patient:129-34.
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ABSTRACT: Technically expedient repair of CDH defects is desirable. With increasing trend toward thoracoscopic repair, herein we examine physiologic predictors for the need for patch closure (PC) versus primary closure. All neonates who underwent surgical repair of CDH defects in a geographically defined region between 1992 and 2002 were included (n = 210). Two groups of patients were compared, primary repair (PR) versus PC. The 25th quartile was used as a cut off point for continuous variables. Univariate and multivariate logistic regression were performed. One hundred and fifty neonates underwent open PR (71.43%) versus 28.57% had PC. On univariate analyses the following variables were significantly associated with the need for PC: prenatal diagnosis, birth weight <2.7 kg, gestational age <37 weeks, APGAR at 5 min <6, immediate postnatal PCO(2) >34, Immediate oxygen saturation <93%, use of Nitric oxide and the need for high frequency oscillation (HFO). On multivariate analyses, only a PCO(2) >34 and the need for HFO were significantly associated with PC. Neonates with an initial PCO(2) >34 or need HFO pre-operatively should be excluded from attempts to repair the CDH thoracoscopically based on their higher potential need for PC with its entailed technical difficulty and increased operative time.
Pediatric Surgery International 06/2008; 24(6):667-70. · 1.25 Impact Factor
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ABSTRACT: Since fulminant Wilsonian liver failure has an extremely poor prognosis, the use of a liver support system that can bridge patients to liver transplant is life saving. We report here the case of a 17-year-old female who presented with fulminant Wilsonian liver failure and intravascular hemolysis. With the subsequent development of encephalopathy and oliguria, single pass albumin dialysis (SPAD) was initiated for 5 days to augment copper removal. Continuous venovenous hemodialysis (CVVHD) was performed using the PRISMA machine, with a blood flow of 100 ml/min and a dialysate flow of 2 L/h for 8 h, then 1 L/h. A 5% albumin dialysate was made by exchanging 1 L of 25% albumin for 1 L of Hemosol BO in a 5-L bag. Single pass albumin dialysis resulted in reductions in serum copper (154 to 59 microg/dL), conjugated bilirubin (37 to 23 mg/dL), lactate dehydrogenase (1305 to 729 units/L), and creatinine (1.1 to 0.9 mg/dL) as well as reduced blood transfusion requirements. Cessation of SPAD was followed by three plasmapheresis treatments for further copper removal. We conclude that SPAD is potentially an effective treatment in fulminant Wilson disease with hemolysis but that it should be used in combination with chelation to optimize the removal of copper.
Pediatric Nephrology 03/2008; 23(6):1013-6. · 2.52 Impact Factor
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ABSTRACT: This study was conducted to examine the preoperative factors predictive of subsequent intervention for gastroesophageal reflux (GER) in children with congenital diaphragmatic hernia (CDH).
We conducted a retrospective cohort study on children who underwent repair of a CDH between January 1, 1995, and December 31, 2002 with follow-up continuing to September 1, 2005. Excluded in the study were children who died during their first admission, or who underwent fundoplication at the time of CDH repair. Univariate and multivariate logistic regressions were performed to examine preoperative factors predictive of subsequent intervention (fundoplication or gastrojejunal tube placement).
Of 86 children, 13 underwent intervention (fundoplication, 10; gastrojejunal tube, 3) for GER. Univariate predictors included the following: right-sided CDH, use of nonconventional ventilation, liver within the chest, and patch closure of the CDH. However, only liver within the chest and patch closure of the CDH were significant predictors in a multiple variable analysis. The positive and negative predictive values of the multivariate model were 69.2% and 87.7%, respectively.
Infants with CDH who have liver within the chest or require patch closure of their hernia are at increased risk for subsequent intervention for GER. These children may represent a subpopulation that would benefit from fundoplication at the time of CDH repair.
Journal of Pediatric Surgery 07/2007; 42(6):1066-70. · 1.45 Impact Factor
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ABSTRACT: Clinically significant pulmonary hypertension (PHTN) is a common finding in newborn infants with congenital diaphragmatic hernia (CDH) resulting in right to left shunting at pre- and postductal level, hypoxemia, and acute right heart failure in those most severely affected. Even in those without clinical manifestations of ductal shunting, cardiac echo studies would suggest that increased pulmonary vascular resistance and right ventricular pressures are almost a universal finding in this disease, and in some instances, may persist well into the postnatal period. The lung is small and structurally abnormal, and the pulmonary vascular bed is not only reduced in size, but responds abnormally to vasodilators. During the last 20 years, "gentle" ventilation, delayed surgery, and improved peri-operative care have made the greatest impact in decreasing mortality in this condition. Use of PGE1 should be considered early if there is hemodynamically significant PHTN, right ventricular dysfunction, and the patent ductus arteriosus (PDA) is becoming restrictive. In individual patients, inhaled nitric oxide (iNO) might be helpful, but the response to iNO should be confirmed using echocardiography. In patients who survive operation and leave the hospital, there are chronic causes of morbidity that need to be looked for and managed in a multi-disciplinary follow-up clinic.
Seminars in Pediatric Surgery 06/2007; 16(2):126-33. · 2.93 Impact Factor
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ABSTRACT: Some patients with severe primary graft dysfunction (PGD) after lung transplantation (LTx) require gas exchange support using an extracorporeal membrane oxygenator (ECMO) as a life-saving therapy. A few single-center experiences have been reported with relatively few cases of ECMO after LTx.
We reviewed outcomes of ECMO in lung transplant recipients included in the Extracorporeal Life Support Organization (ELSO) registry, which was established with the intention to improve quality and outcome of extracorporeal life support (ECLS) in patients treated with ECMO applied for all indications.
The ELSO registry currently includes 31,340 ECMO cases, of which 151 were post-LTx patients with primary graft dysfunction (PGD). The mean age was 35 +/- 18 years. Indications for LTx were acute respiratory distress syndrome, (15%), cystic fibrosis (15%), idiopathic pulmonary fibrosis (8%), primary pulmonary hypertension, (10%), emphysema (15%), acute lung failure (11%), other (23%), and unknown (3%). ECMO run time was 140 +/- 212 hours. Venovenous ECMO was used in 25, venoarterial in 89, and other modes in 15 patients (unknown in 22). ECMO was discontinued in 93 patients owing to lung recovery. It was also discontinued in 29 patients with multiorgan failure, in 22 patients that died with no further specification, and in 7 patients for other reasons. In total, 63 (42%) patients survived the hospital stay. Major complications during ECMO included hemorrhage (52%), hemodialysis (42%), neurologic (12%), and cardiac (28%) complications, inotropic support (77%), and sepsis (15%).
Although the ELSO registry was not primarily established to study ECMO in LTx, it provides valuable insights and evidence that there is indeed an appreciable salvage rate with the use of ECMO for PGD after LTx. Clearly, this is a very high-risk patient population, and no single center can accumulate a large experience of ECMO for this specific indication. These data, however, underscore the importance of developing a specific registry for patients put on ECLS devices so that we can better study the outcomes, determine optimum treatment strategies, and optimize patient and device selection, and thus improve the outcomes of patients requiring this unique therapy.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 06/2007; 26(5):472-7. · 3.54 Impact Factor
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Critical Care Medicine 06/2007; 35(5):1450; author reply 1450-1. · 6.33 Impact Factor
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ABSTRACT: To test whether a drop in effective plasma osmolality (P(Eff osm); 2 x plasma sodium [P(Na)] + plasma glucose concentrations) during therapy for diabetic ketoacidosis (DKA) is associated with an increased risk of cerebral edema (CE), and whether the development of hypernatremia to prevent a drop in the P(Eff osm) is dangerous.
This study is a retrospective comparison of a CE group (n = 12) and non-CE groups with hypernatremia (n = 44) and without hypernatremia (n = 13).
The development of CE (at 6.8 +/- 1.5 hours) was associated with a drop in P(Eff osm) from 304 +/- 5 to 290 +/- 5 mOsm/kg (P < .001). Control patients did not show this drop in P(Eff osm) at 4 hours (1 +/- 2 and 2 +/- 2 vs -9 +/- 2 mOsm/kg; P < .01), because of a larger rise in P(Na) and/or a smaller drop in plasma glucose. During this period, the CE group received more near-isotonic fluids (69 +/- 9 vs 35 +/- 2 and 27 +/- 3 mL/kg; P < .001). The CE group had a higher mortality (3/12 vs 0/57; P = .003), and more neurologic sequelae (5/12 vs 1/57; P < .001).
CE during therapy for DKA was associated with a drop in P(Eff osm). An adequate rise in P(Na) may be needed to prevent this drop in P(Eff osm).
The Journal of pediatrics 05/2007; 150(5):467-73. · 4.02 Impact Factor
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Pediatric Diabetes 09/2006; 7(4):191-5. · 2.16 Impact Factor
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ABSTRACT: The objective of the study was to examine the size and growth of fetal pulmonary artery diameters in congenital diaphragmatic hernia and assess their correlation with postnatal survival and morbidity outcomes.
Prospective antenatal echocardiographic examination of fetal branch pulmonary arteries were correlated with postnatal survival and respiratory morbidity in cases of congenital diaphragmatic hernia. Receiver operator curves were developed to assess their utilization as predictors of respiratory morbidity and survival.
Twenty-one cases were diagnosed antenatally over 3 years. Fifteen subjects survived postnatally. The ipsilateral fetal branch pulmonary artery diameter was smaller throughout gestation in left-sided congenital diaphragmatic hernia (P = .008). The small left pulmonary diameter did not correlate with survival but correlated strongly with morbidity outcomes. Progressive ipsilateral fetal pulmonary artery hypoplasia was demonstrated throughout gestation in subjects who died or had severe morbidity.
Fetal pulmonary artery diameter measurements correlate with respiratory morbidity in postnatal congenital diaphragmatic hernia and may assist with prediction of outcome. Survival has improved, possibly because of improved postnatal management of congenital diaphragmatic hernia, limiting this measurement in assessing survival.
American journal of obstetrics and gynecology 09/2006; 195(2):470-7. · 3.28 Impact Factor
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Nephrology Dialysis Transplantation 09/2006; 21(8):2296-300. · 3.40 Impact Factor
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ABSTRACT: Our objective was to study exercise capacity and cardiorespiratory response to exertion in survivors of congenital diaphragmatic hernia (CDH). This was a cross-sectional cohort study of 23 CDH survivors, aged 10-16 years, and 23 gender- and age-matched controls. Exercise testing was performed on a cycle ergometer, with cardiac output measurements made using exponential CO2 rebreathing. Pretest cardiorespiratory assessment was done by echocardiography and pulmonary function testing. Statistical analysis was performed using Student's t-test, regression analysis, and longitudinal model computing with spatial covariance structure. No echocardiographic evidence for pulmonary hypertension was found at rest (right ventricular systolic pressures, 27 +/- 6 mmHg). Mean pulmonary artery diameter on the side of the CDH was significantly smaller than contralaterally, but was within normal range (z-score, 0 +/- 1.1 vs. 1.2 +/- 1.6, P < 0.01). Exercise capacity was mildly reduced in CDH compared to controls and predictive data (maximum workload, 77% +/- 12% vs. 91% +/- 16% of predicted, P < 0.01). Cardiorespiratory response to exertion was not significantly different between groups. In conclusion, most adolescent CDH survivors have nearly normal exercise capacity and cardiorespiratory response to exertion. This study may prove useful in comparisons with future cohorts comprising more severely affected individuals now surviving due to improved neonatal care.
Pediatric Pulmonology 07/2006; 41(6):522-9. · 2.53 Impact Factor
