Multisystem outcomes and predictors of mortality in critically ill patients with COVID-19: Demographics and disease acuity matter more than comorbidities or treatment modalities.
Identifieur interne : 000087 ( Main/Corpus ); précédent : 000086; suivant : 000088Multisystem outcomes and predictors of mortality in critically ill patients with COVID-19: Demographics and disease acuity matter more than comorbidities or treatment modalities.
Auteurs : Osaid Alser ; Ava Mokhtari ; Leon Naar ; Kimberly Langeveld ; Kerry A. Breen ; Mohamad El Moheb ; Carolijn Kapoen ; Apostolos Gaitanidis ; Mathias A. Christensen ; Lydia R. Maurer ; Hassan Mashbari ; Brittany Bankhead-Kendall ; Jonathan Parks ; Jason Fawley ; Noelle Saillant ; April Mendoza ; Charudutt Paranjape ; Peter Fagenholz ; David King ; Jarone Lee ; Maha R. Farhat ; George C. Velmahos ; Haytham M A. KaafaraniSource :
- The journal of trauma and acute care surgery [ 2163-0763 ] ; 2021.
English descriptors
- KwdEn :
- Acute Kidney Injury (virology), Adult (MeSH), Age Factors (MeSH), Aged (MeSH), Aged, 80 and over (MeSH), Antimalarials (therapeutic use), Boston (epidemiology), COVID-19 (complications), COVID-19 (mortality), COVID-19 (physiopathology), COVID-19 (therapy), Comorbidity (MeSH), Creatine Kinase (blood), Critical Care (MeSH), Critical Illness (MeSH), Extracorporeal Membrane Oxygenation (MeSH), Female (MeSH), Gastrointestinal Diseases (virology), Hospital Mortality (MeSH), Humans (MeSH), Hydroxychloroquine (therapeutic use), Length of Stay (MeSH), Male (MeSH), Middle Aged (MeSH), Neuromuscular Blockade (MeSH), Organ Dysfunction Scores (MeSH), Patient Acuity (MeSH), Pneumonia, Bacterial (virology), Pressure Ulcer (etiology), Prone Position (MeSH), Prospective Studies (MeSH), Respiratory Distress Syndrome (physiopathology), Respiratory Distress Syndrome (virology), Risk Factors (MeSH), SARS-CoV-2 (MeSH), Shock (virology), Steroids (therapeutic use), Survival Rate (MeSH), Thromboembolism (virology), Treatment Outcome (MeSH).
- MESH :
- chemical , blood : Creatine Kinase.
- chemical , therapeutic use : Antimalarials, Hydroxychloroquine, Steroids.
- geographic , epidemiology : Boston.
- complications : COVID-19.
- etiology : Pressure Ulcer.
- mortality : COVID-19.
- physiopathology : COVID-19, Respiratory Distress Syndrome.
- therapy : COVID-19.
- virology : Acute Kidney Injury, Gastrointestinal Diseases, Pneumonia, Bacterial, Respiratory Distress Syndrome, Shock, Thromboembolism.
- Adult, Age Factors, Aged, Aged, 80 and over, Comorbidity, Critical Care, Critical Illness, Extracorporeal Membrane Oxygenation, Female, Hospital Mortality, Humans, Length of Stay, Male, Middle Aged, Neuromuscular Blockade, Organ Dysfunction Scores, Patient Acuity, Prone Position, Prospective Studies, Risk Factors, SARS-CoV-2, Survival Rate, Treatment Outcome.
Abstract
BACKGROUND
We sought to describe characteristics, multisystem outcomes, and predictors of mortality of the critically ill COVID-19 patients in the largest hospital in Massachusetts.
METHODS
This is a prospective cohort study. All patients admitted to the intensive care unit (ICU) with reverse-transcriptase-polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 14, 2020, and April 28, 2020, were included; hospital and multisystem outcomes were evaluated. Data were collected from electronic records. Acute respiratory distress syndrome (ARDS) was defined as PaO2/FiO2 ratio of ≤300 during admission and bilateral radiographic pulmonary opacities. Multivariable logistic regression analyses adjusting for available confounders were performed to identify predictors of mortality.
RESULTS
A total of 235 patients were included. The median (interquartile range [IQR]) Sequential Organ Failure Assessment score was 5 (3-8), and the median (IQR) PaO2/FiO2 was 208 (146-300) with 86.4% of patients meeting criteria for ARDS. The median (IQR) follow-up was 92 (86-99) days, and the median ICU length of stay was 16 (8-25) days; 62.1% of patients were proned, 49.8% required neuromuscular blockade, and 3.4% required extracorporeal membrane oxygenation. The most common complications were shock (88.9%), acute kidney injury (AKI) (69.8%), secondary bacterial pneumonia (70.6%), and pressure ulcers (51.1%). As of July 8, 2020, 175 patients (74.5%) were discharged alive (61.7% to skilled nursing or rehabilitation facility), 58 (24.7%) died in the hospital, and only 2 patients were still hospitalized, but out of the ICU. Age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04-1.12), higher median Sequential Organ Failure Assessment score at ICU admission (OR, 1.24; 95% CI, 1.06-1.43), elevated creatine kinase of ≥1,000 U/L at hospital admission (OR, 6.64; 95% CI, 1.51-29.17), and severe ARDS (OR, 5.24; 95% CI, 1.18-23.29) independently predicted hospital mortality.Comorbidities, steroids, and hydroxychloroquine treatment did not predict mortality.
CONCLUSION
We present here the outcomes of critically ill patients with COVID-19. Age, acuity of disease, and severe ARDS predicted mortality rather than comorbidities.
LEVEL OF EVIDENCE
Prognostic, level III.
DOI: 10.1097/TA.0000000000003085
PubMed: 33891572
Links to Exploration step
pubmed:33891572Le document en format XML
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Kaafarani</name></author></titleStmt><publicationStmt><idno type="wicri:source">PubMed</idno><date when="2021">2021</date><idno type="RBID">pubmed:33891572</idno><idno type="pmid">33891572</idno><idno type="doi">10.1097/TA.0000000000003085</idno><idno type="wicri:Area/Main/Corpus">000087</idno><idno type="wicri:explorRef" wicri:stream="Main" wicri:step="Corpus" wicri:corpus="PubMed">000087</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en">Multisystem outcomes and predictors of mortality in critically ill patients with COVID-19: Demographics and disease acuity matter more than comorbidities or treatment modalities.</title><author><name sortKey="Alser, Osaid" sort="Alser, Osaid" uniqKey="Alser O" first="Osaid" last="Alser">Osaid Alser</name><affiliation><nlm:affiliation>From the Division of Trauma, Emergency Surgery and Surgical Critical Care (O.A., A.M., L.N., K.L., K.A.B., M.E.M., C.K., A.G., M.A.C., L.R.M., H.M., B.B.-K., J.P., J.F., N.S., A.M., C.P., P.F., D.K., J.L., G.C.V., H.M.A.K.), and Division of Pulmonary Critical Care (M.R.F.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.</nlm:affiliation></affiliation></author><author><name sortKey="Mokhtari, Ava" sort="Mokhtari, Ava" uniqKey="Mokhtari A" first="Ava" last="Mokhtari">Ava Mokhtari</name></author><author><name sortKey="Naar, Leon" sort="Naar, Leon" uniqKey="Naar L" first="Leon" last="Naar">Leon Naar</name></author><author><name sortKey="Langeveld, Kimberly" sort="Langeveld, Kimberly" uniqKey="Langeveld K" first="Kimberly" last="Langeveld">Kimberly Langeveld</name></author><author><name sortKey="Breen, Kerry A" sort="Breen, Kerry A" uniqKey="Breen K" first="Kerry A" last="Breen">Kerry A. Breen</name></author><author><name sortKey="El Moheb, Mohamad" sort="El Moheb, Mohamad" uniqKey="El Moheb M" first="Mohamad" last="El Moheb">Mohamad El Moheb</name></author><author><name sortKey="Kapoen, Carolijn" sort="Kapoen, Carolijn" uniqKey="Kapoen C" first="Carolijn" last="Kapoen">Carolijn Kapoen</name></author><author><name sortKey="Gaitanidis, Apostolos" sort="Gaitanidis, Apostolos" uniqKey="Gaitanidis A" first="Apostolos" last="Gaitanidis">Apostolos Gaitanidis</name></author><author><name sortKey="Christensen, Mathias A" sort="Christensen, Mathias A" uniqKey="Christensen M" first="Mathias A" last="Christensen">Mathias A. Christensen</name></author><author><name sortKey="Maurer, Lydia R" sort="Maurer, Lydia R" uniqKey="Maurer L" first="Lydia R" last="Maurer">Lydia R. Maurer</name></author><author><name sortKey="Mashbari, Hassan" sort="Mashbari, Hassan" uniqKey="Mashbari H" first="Hassan" last="Mashbari">Hassan Mashbari</name></author><author><name sortKey="Bankhead Kendall, Brittany" sort="Bankhead Kendall, Brittany" uniqKey="Bankhead Kendall B" first="Brittany" last="Bankhead-Kendall">Brittany Bankhead-Kendall</name></author><author><name sortKey="Parks, Jonathan" sort="Parks, Jonathan" uniqKey="Parks J" first="Jonathan" last="Parks">Jonathan Parks</name></author><author><name sortKey="Fawley, Jason" sort="Fawley, Jason" uniqKey="Fawley J" first="Jason" last="Fawley">Jason Fawley</name></author><author><name sortKey="Saillant, Noelle" sort="Saillant, Noelle" uniqKey="Saillant N" first="Noelle" last="Saillant">Noelle Saillant</name></author><author><name sortKey="Mendoza, April" sort="Mendoza, April" uniqKey="Mendoza A" first="April" last="Mendoza">April Mendoza</name></author><author><name sortKey="Paranjape, Charudutt" sort="Paranjape, Charudutt" uniqKey="Paranjape C" first="Charudutt" last="Paranjape">Charudutt Paranjape</name></author><author><name sortKey="Fagenholz, Peter" sort="Fagenholz, Peter" uniqKey="Fagenholz P" first="Peter" last="Fagenholz">Peter Fagenholz</name></author><author><name sortKey="King, David" sort="King, David" uniqKey="King D" first="David" last="King">David King</name></author><author><name sortKey="Lee, Jarone" sort="Lee, Jarone" uniqKey="Lee J" first="Jarone" last="Lee">Jarone Lee</name></author><author><name sortKey="Farhat, Maha R" sort="Farhat, Maha R" uniqKey="Farhat M" first="Maha R" last="Farhat">Maha R. Farhat</name></author><author><name sortKey="Velmahos, George C" sort="Velmahos, George C" uniqKey="Velmahos G" first="George C" last="Velmahos">George C. Velmahos</name></author><author><name sortKey="Kaafarani, Haytham M A" sort="Kaafarani, Haytham M A" uniqKey="Kaafarani H" first="Haytham M A" last="Kaafarani">Haytham M A. Kaafarani</name></author></analytic><series><title level="j">The journal of trauma and acute care surgery</title><idno type="eISSN">2163-0763</idno><imprint><date when="2021" type="published">2021</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Acute Kidney Injury (virology)</term><term>Adult (MeSH)</term><term>Age Factors (MeSH)</term><term>Aged (MeSH)</term><term>Aged, 80 and over (MeSH)</term><term>Antimalarials (therapeutic use)</term><term>Boston (epidemiology)</term><term>COVID-19 (complications)</term><term>COVID-19 (mortality)</term><term>COVID-19 (physiopathology)</term><term>COVID-19 (therapy)</term><term>Comorbidity (MeSH)</term><term>Creatine Kinase (blood)</term><term>Critical Care (MeSH)</term><term>Critical Illness (MeSH)</term><term>Extracorporeal Membrane Oxygenation (MeSH)</term><term>Female (MeSH)</term><term>Gastrointestinal Diseases (virology)</term><term>Hospital Mortality (MeSH)</term><term>Humans (MeSH)</term><term>Hydroxychloroquine (therapeutic use)</term><term>Length of Stay (MeSH)</term><term>Male (MeSH)</term><term>Middle Aged (MeSH)</term><term>Neuromuscular Blockade (MeSH)</term><term>Organ Dysfunction Scores (MeSH)</term><term>Patient Acuity (MeSH)</term><term>Pneumonia, Bacterial (virology)</term><term>Pressure Ulcer (etiology)</term><term>Prone Position (MeSH)</term><term>Prospective Studies (MeSH)</term><term>Respiratory Distress Syndrome (physiopathology)</term><term>Respiratory Distress Syndrome (virology)</term><term>Risk Factors (MeSH)</term><term>SARS-CoV-2 (MeSH)</term><term>Shock (virology)</term><term>Steroids (therapeutic use)</term><term>Survival Rate (MeSH)</term><term>Thromboembolism (virology)</term><term>Treatment Outcome (MeSH)</term></keywords><keywords scheme="MESH" type="chemical" qualifier="blood" xml:lang="en"><term>Creatine Kinase</term></keywords><keywords scheme="MESH" type="chemical" qualifier="therapeutic use" xml:lang="en"><term>Antimalarials</term><term>Hydroxychloroquine</term><term>Steroids</term></keywords><keywords scheme="MESH" type="geographic" qualifier="epidemiology" xml:lang="en"><term>Boston</term></keywords><keywords scheme="MESH" qualifier="complications" xml:lang="en"><term>COVID-19</term></keywords><keywords scheme="MESH" qualifier="etiology" xml:lang="en"><term>Pressure Ulcer</term></keywords><keywords scheme="MESH" qualifier="mortality" xml:lang="en"><term>COVID-19</term></keywords><keywords scheme="MESH" qualifier="physiopathology" xml:lang="en"><term>COVID-19</term><term>Respiratory Distress Syndrome</term></keywords><keywords scheme="MESH" qualifier="therapy" xml:lang="en"><term>COVID-19</term></keywords><keywords scheme="MESH" qualifier="virology" xml:lang="en"><term>Acute Kidney Injury</term><term>Gastrointestinal Diseases</term><term>Pneumonia, Bacterial</term><term>Respiratory Distress Syndrome</term><term>Shock</term><term>Thromboembolism</term></keywords><keywords scheme="MESH" xml:lang="en"><term>Adult</term><term>Age Factors</term><term>Aged</term><term>Aged, 80 and over</term><term>Comorbidity</term><term>Critical Care</term><term>Critical Illness</term><term>Extracorporeal Membrane Oxygenation</term><term>Female</term><term>Hospital Mortality</term><term>Humans</term><term>Length of Stay</term><term>Male</term><term>Middle Aged</term><term>Neuromuscular Blockade</term><term>Organ Dysfunction Scores</term><term>Patient Acuity</term><term>Prone Position</term><term>Prospective Studies</term><term>Risk Factors</term><term>SARS-CoV-2</term><term>Survival Rate</term><term>Treatment Outcome</term></keywords></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p><b>BACKGROUND</b></p><p>We sought to describe characteristics, multisystem outcomes, and predictors of mortality of the critically ill COVID-19 patients in the largest hospital in Massachusetts.</p></div><div type="abstract" xml:lang="en"><p><b>METHODS</b></p><p>This is a prospective cohort study. All patients admitted to the intensive care unit (ICU) with reverse-transcriptase-polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 14, 2020, and April 28, 2020, were included; hospital and multisystem outcomes were evaluated. Data were collected from electronic records. Acute respiratory distress syndrome (ARDS) was defined as PaO2/FiO2 ratio of ≤300 during admission and bilateral radiographic pulmonary opacities. Multivariable logistic regression analyses adjusting for available confounders were performed to identify predictors of mortality.</p></div><div type="abstract" xml:lang="en"><p><b>RESULTS</b></p><p>A total of 235 patients were included. The median (interquartile range [IQR]) Sequential Organ Failure Assessment score was 5 (3-8), and the median (IQR) PaO2/FiO2 was 208 (146-300) with 86.4% of patients meeting criteria for ARDS. The median (IQR) follow-up was 92 (86-99) days, and the median ICU length of stay was 16 (8-25) days; 62.1% of patients were proned, 49.8% required neuromuscular blockade, and 3.4% required extracorporeal membrane oxygenation. The most common complications were shock (88.9%), acute kidney injury (AKI) (69.8%), secondary bacterial pneumonia (70.6%), and pressure ulcers (51.1%). As of July 8, 2020, 175 patients (74.5%) were discharged alive (61.7% to skilled nursing or rehabilitation facility), 58 (24.7%) died in the hospital, and only 2 patients were still hospitalized, but out of the ICU. Age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04-1.12), higher median Sequential Organ Failure Assessment score at ICU admission (OR, 1.24; 95% CI, 1.06-1.43), elevated creatine kinase of ≥1,000 U/L at hospital admission (OR, 6.64; 95% CI, 1.51-29.17), and severe ARDS (OR, 5.24; 95% CI, 1.18-23.29) independently predicted hospital mortality.Comorbidities, steroids, and hydroxychloroquine treatment did not predict mortality.</p></div><div type="abstract" xml:lang="en"><p><b>CONCLUSION</b></p><p>We present here the outcomes of critically ill patients with COVID-19. Age, acuity of disease, and severe ARDS predicted mortality rather than comorbidities.</p></div><div type="abstract" xml:lang="en"><p><b>LEVEL OF EVIDENCE</b></p><p>Prognostic, level III.</p></div></front></TEI><pubmed><MedlineCitation Status="MEDLINE" Owner="NLM"><PMID Version="1">33891572</PMID><DateCompleted><Year>2021</Year><Month>05</Month><Day>03</Day></DateCompleted><DateRevised><Year>2021</Year><Month>05</Month><Day>03</Day></DateRevised><Article PubModel="Print"><Journal><ISSN IssnType="Electronic">2163-0763</ISSN><JournalIssue CitedMedium="Internet"><Volume>90</Volume><Issue>5</Issue><PubDate><Year>2021</Year><Month>05</Month><Day>01</Day></PubDate></JournalIssue><Title>The journal of trauma and acute care surgery</Title><ISOAbbreviation>J Trauma Acute Care Surg</ISOAbbreviation></Journal><ArticleTitle>Multisystem outcomes and predictors of mortality in critically ill patients with COVID-19: Demographics and disease acuity matter more than comorbidities or treatment modalities.</ArticleTitle><Pagination><MedlinePgn>880-890</MedlinePgn></Pagination><ELocationID EIdType="doi" ValidYN="Y">10.1097/TA.0000000000003085</ELocationID><Abstract><AbstractText Label="BACKGROUND">We sought to describe characteristics, multisystem outcomes, and predictors of mortality of the critically ill COVID-19 patients in the largest hospital in Massachusetts.</AbstractText><AbstractText Label="METHODS">This is a prospective cohort study. All patients admitted to the intensive care unit (ICU) with reverse-transcriptase-polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 14, 2020, and April 28, 2020, were included; hospital and multisystem outcomes were evaluated. Data were collected from electronic records. Acute respiratory distress syndrome (ARDS) was defined as PaO2/FiO2 ratio of ≤300 during admission and bilateral radiographic pulmonary opacities. Multivariable logistic regression analyses adjusting for available confounders were performed to identify predictors of mortality.</AbstractText><AbstractText Label="RESULTS">A total of 235 patients were included. The median (interquartile range [IQR]) Sequential Organ Failure Assessment score was 5 (3-8), and the median (IQR) PaO2/FiO2 was 208 (146-300) with 86.4% of patients meeting criteria for ARDS. The median (IQR) follow-up was 92 (86-99) days, and the median ICU length of stay was 16 (8-25) days; 62.1% of patients were proned, 49.8% required neuromuscular blockade, and 3.4% required extracorporeal membrane oxygenation. The most common complications were shock (88.9%), acute kidney injury (AKI) (69.8%), secondary bacterial pneumonia (70.6%), and pressure ulcers (51.1%). As of July 8, 2020, 175 patients (74.5%) were discharged alive (61.7% to skilled nursing or rehabilitation facility), 58 (24.7%) died in the hospital, and only 2 patients were still hospitalized, but out of the ICU. Age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04-1.12), higher median Sequential Organ Failure Assessment score at ICU admission (OR, 1.24; 95% CI, 1.06-1.43), elevated creatine kinase of ≥1,000 U/L at hospital admission (OR, 6.64; 95% CI, 1.51-29.17), and severe ARDS (OR, 5.24; 95% CI, 1.18-23.29) independently predicted hospital mortality.Comorbidities, steroids, and hydroxychloroquine treatment did not predict mortality.</AbstractText><AbstractText Label="CONCLUSION">We present here the outcomes of critically ill patients with COVID-19. Age, acuity of disease, and severe ARDS predicted mortality rather than comorbidities.</AbstractText><AbstractText Label="LEVEL OF EVIDENCE">Prognostic, level III.</AbstractText><CopyrightInformation>Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.</CopyrightInformation></Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Alser</LastName><ForeName>Osaid</ForeName><Initials>O</Initials><AffiliationInfo><Affiliation>From the Division of Trauma, Emergency Surgery and Surgical Critical Care (O.A., A.M., L.N., K.L., K.A.B., M.E.M., C.K., A.G., M.A.C., L.R.M., H.M., B.B.-K., J.P., J.F., N.S., A.M., C.P., P.F., D.K., J.L., G.C.V., H.M.A.K.), and Division of Pulmonary Critical Care (M.R.F.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Mokhtari</LastName><ForeName>Ava</ForeName><Initials>A</Initials></Author><Author ValidYN="Y"><LastName>Naar</LastName><ForeName>Leon</ForeName><Initials>L</Initials></Author><Author ValidYN="Y"><LastName>Langeveld</LastName><ForeName>Kimberly</ForeName><Initials>K</Initials></Author><Author ValidYN="Y"><LastName>Breen</LastName><ForeName>Kerry A</ForeName><Initials>KA</Initials></Author><Author ValidYN="Y"><LastName>El Moheb</LastName><ForeName>Mohamad</ForeName><Initials>M</Initials></Author><Author ValidYN="Y"><LastName>Kapoen</LastName><ForeName>Carolijn</ForeName><Initials>C</Initials></Author><Author ValidYN="Y"><LastName>Gaitanidis</LastName><ForeName>Apostolos</ForeName><Initials>A</Initials></Author><Author ValidYN="Y"><LastName>Christensen</LastName><ForeName>Mathias A</ForeName><Initials>MA</Initials></Author><Author ValidYN="Y"><LastName>Maurer</LastName><ForeName>Lydia R</ForeName><Initials>LR</Initials></Author><Author ValidYN="Y"><LastName>Mashbari</LastName><ForeName>Hassan</ForeName><Initials>H</Initials></Author><Author ValidYN="Y"><LastName>Bankhead-Kendall</LastName><ForeName>Brittany</ForeName><Initials>B</Initials></Author><Author ValidYN="Y"><LastName>Parks</LastName><ForeName>Jonathan</ForeName><Initials>J</Initials></Author><Author ValidYN="Y"><LastName>Fawley</LastName><ForeName>Jason</ForeName><Initials>J</Initials></Author><Author ValidYN="Y"><LastName>Saillant</LastName><ForeName>Noelle</ForeName><Initials>N</Initials></Author><Author ValidYN="Y"><LastName>Mendoza</LastName><ForeName>April</ForeName><Initials>A</Initials></Author><Author ValidYN="Y"><LastName>Paranjape</LastName><ForeName>Charudutt</ForeName><Initials>C</Initials></Author><Author ValidYN="Y"><LastName>Fagenholz</LastName><ForeName>Peter</ForeName><Initials>P</Initials></Author><Author ValidYN="Y"><LastName>King</LastName><ForeName>David</ForeName><Initials>D</Initials></Author><Author ValidYN="Y"><LastName>Lee</LastName><ForeName>Jarone</ForeName><Initials>J</Initials></Author><Author ValidYN="Y"><LastName>Farhat</LastName><ForeName>Maha R</ForeName><Initials>MR</Initials></Author><Author ValidYN="Y"><LastName>Velmahos</LastName><ForeName>George C</ForeName><Initials>GC</Initials></Author><Author 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