Digital Commons Network^™

Evaluating Bone Fracture Healing In A Rabbit Model Using Doppler Imaging Modes, Shear Wave Elastography, X-Ray, And Dual-Energy X-Ray Absorptiometry, Priscilla Machado, Rachel Blackman, Ji-Bin Liu, Collleen Dempsey, Flemming Forsberg, Traci Fox

Department of Radiology Faculty Papers

OBJECTIVE: This study investigated methods of evaluating the bone fracture healing process using superb microvascular imaging (SMI; two modes color SMI [cSMI] and monochromeSMI [mSMI]), and shear wave elastography (SWE), relative to X-ray, dual-energy X-ray absorptiometry (DXA), and platelet endothelial cell adhesion molecule 1 (PECAM-1) also know as cluster of differentiation 31 (CD-31) staining in a rabbit model.

METHODS: This IACUC-approved study involved eight rabbits that underwent a bilateral fibula osteotomy and were followed for 7 or 21 days (Groups 1 and 2 with 4 rabbits in each). Ultrasound examinations using cSMI, mSMI, and SWE were performed on Days 0, …

Planning For Scale: Analysis Of Adaptations And Contextual Factors Influencing Scale-Up Of The Quali-Dec Intervention To Optimize Caesarean Section Use, Soha El-Halabi, Claudia Hanson, Alexandre Dumont, Amanda Cleeve, Helle Mölsted Alvesson, Charles Kaboré, Guillermo Carroli, Pisake Lumbiganon, Quoc Nhu Hung Mac, Ana Pilar Betran

Centre of Excellence in Women and Child Health

Background: Researchers are encouraged to plan for scale through purposeful and guided assessment of scalability of an intervention. This study analysed factors potentially influencing scale-up and synthesised early adaptations of the QUALI-DEC intervention aiming to improve the appropriate use of caesarean section. The intervention consists of opinion leader engagement, audit and feedback for caesarean section, a tool to help women make an informed decision on the mode of birth, and labour companionship.

Methods: We conducted a framework analysis, which was guided by the scalability assessment framework by Zamboni et al., a 34-item checklist with a three-point scale. We used data …

Pregnancy Care Integrating Translational Science, Everywhere (Precise): A Prospective Cohort Study Of African Pregnant And Non-Pregnant Women To Investigate Placental Disorders – Cohort Profile, Rachel Craik, Joseph Akuze, Marie-Laure Volvert, Hannah Blencowe, Moses Mukhanya, Angela Koech, Grace Mwashigadi, Marleen Temmerman, Marvin Ochieng, Emily Mwadime

Centre of Excellence in Women and Child Health

Purpose: The Pregnancies' Care Integrating translational Science, Everywhere Network was established to investigate specific placental disorders (pregnancy hypertension, preterm birth, fetal growth restriction and stillbirth) in sub-Saharan Africa. We created a repository of clinical and social data with associated biological samples from pregnant and non-pregnant women. Alongside this, local infrastructure and expertise in the field of maternal and child health research were enhanced.

Participants: Pregnant women were recruited in participating health facilities in The Gambia, Kenya and Mozambique at their first antenatal visit or at the time a placental disorder was diagnosed (Kenya and The Gambia only). Follow-up study …

Associations Between The Timing Of 24 H Physical Activity And Diabetes Mellitus: Results From A Nationally Representative Sample Of The Us Population, Qian Xiao, Qiuyu Feng, Martin K Rutter, Gali Albalak, Heming Wang, Raymond Noordam

Faculty, Staff and Student Publications

Aims/hypothesis: Growing evidence suggests that timing may be an important aspect of physical activity that influences cardiometabolic health. However, the current literature is inconclusive regarding the time of day that physical activity offers the greatest metabolic advantages. We investigated associations between hourly physical activity levels and diabetes mellitus and glycaemic biomarkers in a cross-sectional and nationally representative sample of US adults.

Methods: We studied 7074 adults (mean age 48 years; 52% women) from the National Health and Nutrition Examination Survey (2011-2014). Physical activity was measured by actigraphy. A monitor-independent movement summary (MIMS) unit was used to derive the total activity …

Beyond Opioids: The Role Of Polysubstance Exposure In Neonatal Abstinence Syndrome Treatment And Hospitalization, Caelyn Harrison

Undergraduate Honors Theses

This thesis explores the impact of prenatal polysubstance exposure, specifically focusing on the need for pharmacological treatment for Neonatal Abstinence Syndrome (NAS) and the duration of their hospital stay. A retrospective analysis of 462 infants, including 121 exposed to polysubstances during pregnancy, showed significant associations between polysubstance exposure and adverse neonatal outcomes. Infants with prenatal polysubstance exposure were more likely to require pharmacological treatment for NAS (52.8%) compared to non-exposed infants (38.7%), as determined by chi-square analysis (χ²(1, N = 462) = 7.36, p = .007). Additionally, infants exposed to polysubstances experienced longer hospital stays on average (M = 14.88 …

Navigating Challenges In Palliative Care: A Survey On Asco Guideline Adherence Among Health Care Providers In Low- And Middle-Income Countries., Cristiane Decat Bergerot, Enrique Soto-Perez-De-Celis, Chadane Thompson, Rushil Patel, Jafar Al-Mondhiry, Tingting Zhang, Nathasha Dhawan, Darcy Burbage, Joseph Mccollom Do, Mazie Tsang, Ramy Sedhom, William E Rosa

PCI Publications and Projects

PURPOSE: Integrating palliative care into oncology is essential, yet disparities in access and quality persist, particularly in low- and middle-income countries (LMICs). The ASCO guidelines advocate for early, routine, interdisciplinary palliative care for patients with advanced cancer. Barriers to implementing these recommendations include resource limitations, inadequate training, and cultural perceptions. Recognizing these challenges is essential for improving equitable access to palliative care worldwide.

METHODS: This prospective survey assessed adherence to ASCO recommendations for palliative care integration among LMIC health care providers (HCPs). Participants were recruited via e-mail, social media, and a list of members involved in the ASCO Palliative Care …

Lefitolimod In Combination With Ipilimumab In Patients With Advanced Solid Tumors: A Phase I Trial, Mirella Nardo, Mohamed A Gouda, Matthew J Reilley, Amadeo B Biter, Joann Lim, Stacie A Bean, Ly M Nguyen, Priya R Bhosale, Casey R Ager, Coline A Couillault, Sarina A Piha-Paul, Siqing Fu, Apostolia M Tsimberidou, Timothy A Yap, Aung Naing, Jordi Rodon, Vivek Subbiah, Daniel D Karp, Michael A Curran, David S Hong

Faculty, Staff and Student Publications

Introduction: TLR9 agonists are immunomodulators that have been of interest for combined use with cancer immunotherapy. TLR9 agonists, such as lefitolimod (MGN1703), significantly increased Th1 response in preclinical models and have demonstrated efficacy in early clinical trials. This trial assessed the safety and preliminary efficacy of the combination of lefitolimod and ipilimumab in patients with advanced solid tumors.

Methods: This was a single-center, open-label, investigator-initiated phase I trial conducted at The University of Texas MD Anderson Cancer Center. Patients received leftolimod either subcutaneously (at escalating doses of 15-120 mg) or intratumorally (at the maximum feasible dose) in combination with ipilimumab …

Tumoral And Circulating Genomic Landscape Inform Survival Differences In Colorectal Carcinomatosis, Michael G White, Reed I Ayabe, Mohammad A Zeineddine, Fadl A Zeineddine, Abdelrahman M G Yousef, Mahmoud Yousef, Norman J Galbraith, J Bryan Iorgulescu, Christopher Scally, Keith Fournier, Timothy E Newhook, Nancy Y You, Jason Willis, Scott Kopetz, George J Chang, John Paul Shen, Abhineet Uppal

Faculty, Staff and Student Publications

Colorectal peritoneal metastases (CPM) are the third most common site of metastatic spread of colorectal cancer and are associated with worse survival than other sites of metastatic disease. In recent years tumoral circulating tumoral DNA (ctDNA) mutational status has been increasingly utilized in clinical decision making for metastatic colorectal cancer patients despite its utility in CPM being poorly understood. Here we describe standard of care performed mutational profiles and associated outcomes for unresectable CPM patients, with a contextual comparison to 160 unresected colorectal liver metastases (CLM) patients. Of 508 patients, 288 (57 %) had CPM alone and 220 (43 %) …

Unveiling The Intercompartmental Signaling Axis: Mitochondrial To Er Stress Response (Mersr) And Its Impact On Proteostasis, Jeson J Li, Nan Xin, Chunxia Yang, Bo G Kim, Larissa A Tavizon, Ruth Hong, Jina Park, Travis I Moore, Rebecca George Tharyan, Adam Antebi, Hyun-Eui Kim

Faculty, Staff and Student Publications

Maintaining protein homeostasis is essential for cellular health. Our previous research uncovered a cross-compartmental Mitochondrial to Cytosolic Stress Response, activated by the perturbation of mitochondrial proteostasis, which ultimately results in the improvement of proteostasis in the cytosol. Here, we found that this signaling axis also influences the unfolded protein response of the endoplasmic reticulum (UPRER), suggesting the presence of a Mitochondria to ER Stress Response (MERSR). During MERSR, the IRE1 branch of UPRER is inhibited, introducing a previously unknown regulatory component of MCSR. Moreover, proteostasis is enhanced through the upregulation of the PERK-eIF2α signaling pathway, increasing phosphorylation of eIF2α and …

Using A Surgical Risk Predictor To Estimate Percutaneous Cryoablation Adverse Event Risk: A Single Center Comparative Analysis, Prisha Patel, Koustav Pal, Hadi Ahmed, Bill Tang, Iwan Paolucci, Mohammad Khavandi, Peiman Habibollahi, Ketan Shah, Steven Y Huang, Bruno C Odisio, Sanjay Gupta, Kamran Ahrar, Steven Yevich, Joshua D Kuban, Alda Tam, Rahul A Sheth

Faculty, Staff and Student Publications

Objective: To evaluate the relevance of established surgical risk calculators for predicting complications in patients undergoing percutaneous lung cryoablation (PLC).

Methods: The institution's database was queried for PLC procedures from March 2015 to May 2024, excluding those patients with concomitant local therapies or five or more lesions treated in a single setting. Demographics, frailty metrics as defined by the surgical literature, and procedural variables were collected. To evaluate the suitability of surgical risk estimate calculators, the requisite demographic data were input into the American College of Surgery surgical risk calculator; estimates for length of stay (LOS), serious complications, 30-day readmission, …

Natural History Models For Lung Cancer: A Scoping Review, Renu Sara Nargund, Sayaka Ishizawa, Maryam Eghbalizarch, Paul Yeh, Seyyed Mostafa Mousavi Janbeh Saray, Sara Nofal, Yimin Geng, Pianpian Cao, Edwin J Ostrin, Rafael Meza, Martin C Tammemägi, Robert J Volk, Maria A Lopez-Olivo, Iakovos Toumazis

Faculty, Staff and Student Publications

Introduction: Natural history models (NHMs) of lung cancer (LC) simulate the disease's natural progression providing a baseline for assessing the impact of interventions. NHMs have been increasingly used to inform public health policies, highlighting their utility. The objective of this scoping review was to summarize existing LC NHMs, identify their limitations, and propose a framework for future NHM development.

Methods: We searched MEDLINE, Embase, Web of Science, and IEEE Xplore from their inception to October 5, 2023, for peer-reviewed, full-length articles with an LC NHM. Model characteristics, their applications, data sources used, and limitations were extracted and narratively synthesized.

Results: …

Dose Prediction Via Deep Learning To Enhance Treatment Planning Of Lung Radiotherapy Including Simultaneous Integrated Boost Techniques, Wenhua Cao, Mary Gronberg, Stephen Bilton, Hana Baroudi, Skylar Gay, Christopher Peeler, Zhongxing Liao, Thomas J Whitaker, Karen Hoffman, Laurence E Court

Faculty, Staff and Student Publications

Background: Recent studies have shown deep learning techniques are able to predict three-dimensional (3D) dose distributions of radiotherapy treatment plans. However, their use in dose prediction for treatments with varied prescription doses including simultaneous integrated boost (SIB), that is, using multiple prescription doses within the same plan, and benefit in improving plan quality should be validated.

Purpose: To investigate the feasibility and potential benefit of using deep learning to predict dose distribution of volumetric modulated arc therapy (VMAT) including SIB techniques and improve treatment planning for patients with lung cancer.

Methods: The dose prediction model was trained with 93 retrospective …

Post-Operative Hemodynamic Instability After Tcar (Transcarotid Artery Revascularization): A Retrospective Study, Lutfi Barghuthi, Rebekah Bjorklund, Mya Phelps, Shrina Patel, Lakecia Beasley, Bayli Zink, Alyssa Bedell, Gaurav Singh, Sarah Stokke, Rebecca Swindall, Allen Cook, Mark Robbins

School of Medicine Student Publications and Presentations

Introduction: Postoperative hemodynamic instability following carotid revascularization can lead to adverse outcomes such as Intensive Care Unit (ICU) admission and prolonged hospitalization, leading to an increase in total hospital charges. This study aimed to compare hemodynamic instability between Transcarotid Artery Revascularization (TCAR) and Carotid Endarterectomy (CEA) in a rural setting. Methods: A retrospective cohort study was conducted at a single institution on treatment for carotid artery stenosis between 2021 and 2024. Clinical outcomes following TCAR and CEA were compared. The primary outcome was hemodynamic instability; secondary outcome was ICU admission. Results: In total, 546 patients were included, 72.5% undergoing TCAR …

Toward The Application Of Natural Language Processing In Electronic Health Record Analysis For Taxonomy Development, Latoya Mcdonald

All Dissertations

Electronic health records (EHRs) are pivotal resources for nurse practice because they increase the timeliness and reliability of patient information at the point of care and support access by multiple healthcare providers and the individual patients themselves. However, it is widely recognized that data extraction from EHRs is challenging due to the variability in the language used in clinical care notes and the lack of standardized terminology across healthcare systems. The broad objective of this dissertation is to develop taxonomy-based classification models for nursing care by applying feature engineering approaches to EHRs that include nursing care of ostomy patients following …

Perspectives On Clinical Oncogenomics: Secondary Germline Variants Associated With Tumor Genomic Profiling In Community Cancer Care And Advanced Practitioner Oncogenomic Proficiency, Sarah Moncado

All Dissertations

Precision medicine in oncology is defined by the sequencing of tumor genomic variants that can be used to identify targeted treatment for patients. Secondary pathogenic and likely pathogenic germline variants (P/LPGVs) can incidentally be detected on tumor genomic profiling (TGP). With the rise in precision medicine over the past 15 years, secondary P/LPGVs on TGP have been an increasingly important clinical issue. However, there are factors that can lead to misidentification and underreporting of P/LPGVs. Germane to this clinical practice issue is healthcare provider oncogenomic literacy and proficiency.

A scoping review was conducted to evaluate the variability of the prevalence …

Serendipitous Supernormality, Behzad B. Pavri, Eitan Frankel

Division of Cardiology Faculty Papers

We describe a patient who underwent AV node modification to create complete heart block in the setting of incessant, ablation-and-drug-refractory, symptomatic atypical atrial flutter. His dual chamber defibrillator (previously implanted for resuscitated cardiac arrest) was programmed to the VVIR mode at a faster pacing rate of 85 bpm. Serendipitously, this rate was an almost exact factorial of his flutter rate of 250-260 bpm. This resulted in every 6th flutter wave falling in the supernormal period, resulting in fixed-coupled supraventricular bigeminy and trigeminy in the setting of complete heart block. Reprogramming the pacing rate to 75 bpm abolished bigeminy and trigeminy.

The Role Of Responsive Feeding In Childhood Development And Clinical Implications: A Comprehensive Literature Review, Alexander Burbach

Capstone Experience: Master of Public Health

Responsive feeding refers to caregiver-infant feeding interactions that encourage healthy eating behaviors and support the child’s autonomy by responding to their hunger and satiety cues. Responsive feeding supports healthy early childhood development, influencing self-regulation in eating behaviors and long-term health outcomes, particularly in obesity prevention. A comprehensive literature review was conducted to examine the impact of responsive feeding practices on childhood development in the United States and its clinical implications. The objectives were to explore the role of parental feeding practices in shaping childhood eating behaviors, understand the relationship between responsive feeding and obesity, and determine literature daps. Articles for …

Evaluating Surge Capacity In The Emergency Department: A Comprehensive Literature Review On Preparedness And Response Frameworks, Tanner J. Riscoe

Capstone Experience: Master of Public Health

Medical surge capacity in emergency departments is influenced by four critical factors: staff, stuff, space, and systems. Understanding these factors and the interplay between them is critical. Emergency departments are increasingly encountering issues with overcrowding, patient boarding, and medical surge events causing interruptions in care and depleting critical resources. Coordination of medical surge is challenging during normal operations but is intensified during times of crisis. This comprehensive literature review seeks to better understand the current state of the literature surrounding surge preparedness and response in emergency departments across the United States, identify gaps in the current literature, and ultimately recommend …

A Comprehensive Literature Review Of Barriers To Hormone Therapy Utilization: Strategies For Improving Menopause Management In Women Aged 40-60, Suhan Lee

Capstone Experience: Master of Public Health

Menopause is a natural transition marked by the cessation of ovarian activity, often accompanied by vasomotor symptoms (VMS), genitourinary syndrome of menopause (GSM), and psychological changes that significantly impact women’s quality of life. Hormone therapy (HT) has been the primary treatment for managing menopausal symptoms, particularly VMS, providing substantial relief when initiated within 10 years of menopause. Despite its effectiveness, HT usage has declined dramatically over the past two decades primarily due to barriers such as stigma, safety, misinformation, provider hesitancy, financial barriers, and cultural beliefs. This comprehensive literature review explores key factors influencing HT decision-making, including the media’s role …

The State Of Abortion Training In Medical School And Family Medicine Residency Curricula: A Scoping Literature Review, Eric James Reece

Capstone Experience: Master of Public Health

This project aims to assess how abortion education has been integrated into medical training over the past decade, with a particular focus on understanding its current state in medical schools and family medicine residencies, including those offering specialized programs affiliated with RHEDI (Reproductive Health Education in Family Medicine) and TEACH (Training in Early Abortion for Comprehensive Healthcare). Given the ever-evolving legal landscape following the June 4^th, 2022 Supreme Court case of Dobbs v. Jackson Women’s Health Organization, this review explores how both federal- and state-level legal restrictions impact access to abortion training and attempts to identify gaps …

Safety And Utility Of Robotics In Pediatric Surgery: Implementation, Luke J. Man, Kristin Lemarbe, Nathan Novotny, Anthony Stallion, Begum Akay, Pavan Brahmamdam

Posters

• Minimally invasive laparoscopic surgery is considered standard of care for adult and pediatric patients .

• Robotic surgery (RS) for adult patients has been widely adopted due to superior ergonomics, visualization, depth perception, and access to deeper anatomical structures2,3.

• Historically, RS is associated with longer operative times, higher cost, and lacks haptic feedback1,2.

• RS has had inconsistent adoption in the pediatric surgery community2.

Improving Treatment For Infant Perianal Abscesses, Artem Dadamyan, Nathan Novotny, Ngan Nguyen

Posters

Perianal abscesses: • Tender masses located at the anal verge, typically in the 3 o’clock and 9 o’clock positions1

• Develop due to infection in abnormally deep crypts of Morgagni 1

• If left untreated, can extend into the ischioanal space or intersphincteric space since these areas are continuous with the perianal space.2

• Some may develop into fistula in ano, which can be difficult to treat3 Treatment:

• The standard has always been incision and drainage (I&D), but non-invasive management of Sitz baths is increasingly being used.

The Relevance Of Age, Bmi, And Right Versus Left Ear Surgery To The Incidence Of Taste Disturbance After Stapes Surgery, Jonathan Ong, Dennis Bojrab Ii

Posters

• Many factors such as age and body mass index (BMI) have been shown to influence post-operative outcomes in patients undergoing stapedectomy/stapedotomy.

• This study examines these factors to see if they have any impact on the incidence of taste disturbance, a commonly reported complication of stapes surgery.1

• Our study predicts that BMI and age are correlated with the incidence of taste disturbance post-operatively following stapes surgery.

Do Critically Ill Patients With Guardianships Receive More Aggressive Treatment?, Misha Haq, Jacob Keeley, Enrique Calvo-Ayala

Posters

• Patients suffering from certain conditions can become unable, unwilling, or unavailable to make decisions regarding their end-of-life care1.
• • In these cases, a court appointed guardian is responsible for carrying out medical decisions on behalf of the patient2.
• Patients with guardians tend to receive more aggressive care, regardless of the benefit, because it is perceived as safer 3.
• Guidelines and laws for medical decision-making for patients with guardians are inconsistent, leaving this population vulnerable4.

Low Cpap Adherence Amongst The African American And Arabic Population In Patients With Obstructive Sleep Apnea, Nikki Nguyen, Bhavinkumar Dalal

Posters

• Obstructive sleep apnea (OSA) is a breathing disorder that occurs from a recurring decreased or completely blocked airflow during sleep leading to symptoms including excessive daytime sleepiness and impaired cognitive function1.

• Primary treatment for moderate to obstructive sleep apnea is continuous positive airway pressure (CPAP) reducing daytime sleepiness, improves neurocognitive function, and improves quality of life2.

• Current literature shows that compliance varies from 40-85% with poor adherence reducing the treatment’s effectiveness in preventing chronic health problems3.

• Although more CPAP use is generally associated with subjective and adherence is typically defined as at least 4 hours of …

Associations Between Health Literacy And Comprehension Of Health Visits In A Community Setting, Amanda Romaya, Adel Andemeskel, Salim Abdul-Razak, Linda Dillon, Victoria Lucia

Posters

Low health literacy is a significant social determinant of health that is associated with poor health outcomes1-3. Bringing attention to health literacy will aid in promoting the health of the population. However little has been done to implement national policies and interventions that address patient health literacy, especially in a community setting4.

We hypothesized that our assessment of the identified patient population’s health literacy will not meet adequate standards and will indeed demonstrate a need for community-focused interventions

Predicting Coronary Artery Calcium Using Abdominal Aorta And Visceral Artery Calcification, Jared Dixon, Sayf Al-Katib, Kiran Nandalur, Jacob Ghannam, Ali Beydoun, Desiree Clement

Posters

CAC scoring has emerged as a widely available, consistent, and reproducible means of assessing risk for major cardiovascular outcomes, especially useful in asymptomatic people for planning primary prevention interventions such as statins and aspirin.1 The Multiethnic Study of Atherosclerosis (MESA) demonstrated that a CAC score of 0 represents a less than 5 percent 10-year Atherosclerotic cardiovascular disease (ASCVD) risk. CAC scores 1-299 represent borderline to intermediate risk, and CAC score >300 represents a “high risk” 10 percent or greater 10-year ASCVD risk.2

When used correctly, CAC scoring is a powerful predictor of ASCVD risk and holds the key for many …

Advances In Minimally Invasive Hepatobiliary Interventions For Non-Operative Candidates, Tulasi Talluri, Philip Cieplinski, Kristian Loveridge

Posters

Cholangioscopy is a technique used for diagnosing and treating patients with pathologies of the gallbladder, liver, and pancreas. It has been available since 1976 but with limited use in interventional radiology (IR) due to issues with steerability, irrigation capabilities, requirement for more than one operator, and poor percutaneous access options; however, direct intraluminal visualization of the gallbladder, common bile ducts, and even the ampulla and duodenum has become more practical with the advent of single operator percutaneous systems. Access to the biliary system can now be made through smaller 11 French sheath/delivery systems allowing for improved maneuverability into the common …

Allergies Coinciding With Central Sensitization Syndromes (Access), Jacqueline Morey, Alemu Fite, Carl Lauter, Matthew Sims

Posters

Significance of Reported Allergies: Many reported drug allergies are mislabeled side effects or misinterpretations, leading to suboptimal treatment, antibiotic resistance, and worse patient outcomes.¹

Central Sensitization Syndromes (CSS): CSSs are chronic pain conditions linked to altered sensory perception, including pain, fatigue, and neurologic dysfunction.² These patients may be more likely to misattribute medication side effects as allergies.

Previous Findings & Hypothesis: Prior research found high allergy reporting in interstitial cystitis and fibromyalgia—both CSS conditions.⁴ We hypothesized that other CSS diagnoses also correlate with increased allergy reporting, emphasizing the need for better allergy evaluation.

Surgical Site Infection Bundle For Babies: Preliminary Data, Cullen Woodley, John Nida, Alexis Lonjin, Katelyn Ward, Diane Studzinski, Begum Akay

Posters

Surgical Site Infections (SSIs) are infections that occur in or around the area where a surgery was recently performed. They are estimated to account for 20% of all healthcare associated infection, and lead to an increase in morbidity and mortality. Perioperative care bundles show promise in reducing SSIs in adults but are not often used in neonatal surgery. Infections in babies after surgery are less common than adults but carry significant morbidity in a fragile patient.